THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


I 


GENERAL  SURGERY 


"•^Q^ 


GENERAL  SURGERY 


A   PRESENTATION  OF  THE  SCIENTIFIC  PRINCIPLES   UPON 
WHICH   THE    PRACTICE   OF  MODERN   SURGERY  IS  BASED 


BY 

ERICH   LEXER,   M.D. 

PEOFKSSOR  OF  SURGERY,    UNIVERSITY   OF  KONIGSBERG 

AMERICAN   EDITION 
EDITED   BY 

ARTHUR   DEAN   RE  VAN,  JNID. 

PROFESSOR   AND   HEAD    OF   THE    DEPARTMENT   OF   SURGERY,    RUSH    MEDICAL 
COLLEGE  IN   AFFILIATION   WITH  THE    UNIVERSITY  OF  CHICAGO 


AN  AUTHORIZED  TRANSLATION  OF  THE 
SECOND   GERMAN    EDITION 

BY 

DEAN    LEWIS,    M.D. 

ASSISTANT  PROFESSOR  OF  SURGERY,   RISH  MEDICAL  COLLEGE   IN   AKFII.IATION 
WITH  THE    UNIVERSITY   OF  CHICAGO 


WITH  FOUR  HUNDRED  AND   FORTY-NINE  ILLUSTRATIONS  IN  THE 
TEXT,   PARTLY  IN  COLOR,   AND   TWO   COLORED  PLATES 


D .     A  P  P  L  E  T  O  N     AND     C  O  M  P  A  N  Y 
NEW     YORK     AND     LONDON 

1910 


Copyright,  1908,  1910,  by 
D.   APPLETON   AND  COMPANY 


PRINTKI)    AT   THE    APPI.KTON    PRESS 
NEW    Y^ORK,    U.    S.    A. 


liMwdieal 

Likraiy 

PREFACE 


My  associate,  Dr.  Lewis,  and  myself  have  undertaken  the  translatinj? 
and  editing  of  this  text-book  on  General  Surgery,  written  by  Prof. 
Erich  Lexer,  because  we  believe  that  it  presents  the  present  status  of 
the  subject  of  general  surgery  in  a  more  thorough  and  complete  way 
than  any  other  text-book. 

This  work  is  a  presentation  of  the  scientific  principles  upon  which 
the  practice  of  modern  surgery  is  based. 

In  text-books  on  surgery  in  all  languages  two  great  divisions  of  the 
subject  are  made,  and  to  these  two  divisions  of  the  subject  various  names 
have  been  given.  In  England  and  America,  the  terms  the  Science  and 
Art  of  Surgery  and  the  Principles  and  Practice  of  Surgery  have  been 
generally  employed.  On  the  Continent,  the  terms  General  and  Special 
Surgery  are  used. 

These  latter  seem  to  me  preferable,  and  we  have  therefore  retained 
the  term  General  Surgery  in  our  American  edition  of  Professor  Lexer's 
work,  and  hope  that  this  may  be  adopted  by  the  American  and  English 
profession.  There  are  certain  general  principles  of  pathology  and  thera- 
peutics and  operative  technie  which  apply  to  all  fields  of  surgery,  ami 
when  these  are  thoroughly  mastered  by  the  student  or  ])raetitioner  their 
application  to  special  surgical  conditions  becomes  at  once  intelligent  and 
easy  and  scientific.  For  him  who  lacks  this  knowledge  the  practice  of 
surgery  becomes  a  handicraft. 

The  subject  of  General  Surgery  should  be  studied  by  the  student 
before  regional  or  special  surgery  is  taken  up.  In  our  own  surgical 
department,  the  ground  covered  in  this  book  is  studied  in  the  third 
year  in  a  course  extending  over  a  period  of  six  months,  three  hours  each 
week  being  devoted  to  recitations,  conferences,  and  ]al)oratory  work. 
This  work,  with  the  addition  of  a  six  months'  courst-  in  surgical  anat- 
omy, is  made  prerequisite  to  the  study  of  regional  and  special  surgery. 

Practitioners  who  are  interested  in  surgery  will  find,  I  believe,  great 
interest  and  profit  in  studying  this  book.  The  advances  in  tlie  science 
of  surgery  in  the  last  few  years  have  been  so  rapid  and  so  great  that  it 
has  been  difficult  for  the  surgeon  engaged  in  active  practice  to  keep 
abreast  of  the  increasing  knowledge.     As  an  example  one  might  men- 


603479 


VI  PREFACE 

tion  the  significance  and  importance  of  the  modern  conception  of  infec- 
tion and  immunity,  and  the  application  of  this  knowledge  to  surgery. 
Professor  Lexer  has  presented  these  modern  views  in  a  clear,  concise, 
and  practical  way.  This  English  translation  will  offer  to  those  who  do 
not  read  German  a  most  complete  presentation  of  the  present  status  of 
the  Science  of  Surgery,  a  department  in  which  our  German  colleagues 
excel.  Dr.  Lewis  and  I  have  not  hesitated  to  make  such  additions  and 
changes  as  seemed  to  us  desirable  to  make  the  book  more  complete. 

Special  attention  is  called  to  the  excellent  chapter  on  Blastomycosis, 
written  by  Dr.  Oliver  Ormsby.  This  disease  has  been  especially  studied 
in  America.  The  Continental  authorities  have  not  had  much  experi- 
ence wdth  the  disease,  and  have  been  rather  skeptical  about  it.  I  hope 
that  Dr.  Ormsby 's  chapter  will  be  included  in  the  next  German  edition. 

The  chapters  by  Dr.  Kosenow^,  on  blood  examinations  in  surgery,  and 
also  on  the  subject  of  opsonins  and  the  Wright  vaccination  treatment, 
are  a  distinct  addition.  Dr.  George  Crile  has  kindly  allowed  us  to 
publish  an  abstract  of  his  recent  work  on  the  direct  transfusion  of  blood. 

We  have  retained  most  of  the  illustrations  of  the  German  edition, 
and  have  added  a  number  of  plates  taken  largely  from  our  own  clinic. 

I  desire  to  express  my  appreciation  of  the  work  of  D.  Appleton  & 
Company,  the  publishers,  who  kindly  undertook  this  publication  at  my 
suggestion,  and  who  have  spared  no  pains  to  make  the  work  acceptable 
in  every  way.  I  feel  that  Professor  Lexer's  book  is  most  valuable  and 
timely,  and  in  offering  this  English  edition  to  the  profession  I  desire 
to  express  the  hope  that  it  will  be  widely  read,  and  that  those  who  read 
it  may  find  it  as  profitable  and  instructive  as  I  have. 

Arthur  Dean  Bevan. 
100  Statje  Street,  Chicago,  III. 


TABLE   OF  CONTENTS 


PART   I 

/.     WOUXDS,    THEIR    TREATMEXT   AND   REPAIR 

Chapter  I. — Wounds.  pj^^.s 

Different  Kinds  of  Wounds 1 

Pain  in  Wounds,  Haemorrhage 3 

Chapteh  II. — -Treatment  of  Wounds. 

Temporary  Control  of  Hit-morrhage o 

Artificial  Ischa^mia 6 

Definitive  Control  of  Ila-morrhage 0 

Diseases  of  the  Blood 12 

Loss  of  Blood,  Dangers  of,  Death  from 14 

Blood-letting 15 

Transfusion  of  Blood,  of  Salt  Solution 16 

Harmful  Agents 18 

Suture  of  Wounds 22 

Tampon  of  Iodoform  Gauze 27 

Moist  Dressings 28 

Carbolic  Acid  Necrosis 29 

Iodoform  Intoxication 31 

Drainage 32 

Removal  and  Encapsulation  of  Foreign  Bodies     ....  32 

Chapter  III. — Wound  Repair. 

Primary  l^nion 35 

Secondary  Ihiion 39 

Healing  Beneath  a  Scab 41 

Unhealthy  Granulation  Tissue -^3 

Action  of  Foreign  Bodies J  •"> 

Healing  of  Transplanted  Tissues 40 

II.     ASEPTIC   TECHNIC 

Introduction 51 

Chapter  I. — Preparation  of  Surface  of  the  Body. 

o.  Hand  Sterilization 53 

h,  Sterilization  of  the  Field  of  Operation 59 

c,  Sterilization  of  Mucous  Membranes 59 

Chapter  II. — Sterilization  of  Instruments GO 

vii 


viii  TABLE  OF  CONTENTS 

PAGES 

Chapter  III. — Sterilization  of  Sponges,  Dressings,  and  Linen         .        .  63 

Preparation  of  Iodoform  Gauze 66 

Chapter  IV. — Sterilization  of  Sutures  and  Ligatures, 

a,  Silk 67 

6,  Silkworm  Gut 68 

c,  Metal  Sutures 68 

d,  Catgut 68 

Chapter  V. — Operating  Room 71 

Chapter  VI. — The  Aseptic  Operation 73 

Chapter  VII. — Asepsis  and  Aseptic  Technic  in  Private  Practice     .        .  79 

///.     GENERAL   AND  LOCAL   ANAESTHESIA 

Chapter  I. — Chloroform  Anesthesia        .        .        .        .        .        .        .        .86 

Chapter  II. — Ether  Anesthesia 99 

Chapter  III. — Nitrous  Oxid  Anesthesia 105 

Chapter  IV. — Accidents  During  Anesthesia  and  Ways  to  Meet  Them  107 

Chapter  V. — Different  Methods  of  Inducing  Anesthesia. 

Choice  of  Methods 113 

Chapter  VI. — Local  Anesthesia 119 

IV.     GENERAL  PRINCIPLES  OF  PLASTIC  OPERATIONS 

Chapter  I. — Classification  of  Plastic  Procedures 127 

Chapter  II. — Fundamental  Rules  for  Plastic  Operations        .        .        .  133 
Chapter  III. — Plastic  Operations  with  Compound  Flaps  and  Transplan- 
tation of  Mucous  Membrane,  Cartilage,  and  Bone   .  139 


PART  IT 

WOUND   INFECTIONS   AND   SURGICAL   INFECTIOUS   DISEASES 
7.     NATURE  OF  INFECTION,   LOCAL   AND  GENERAL   REACTION 

Chapter  I. — Nature  of  Infection 143 

Chai'tkr  II. — Local  Reaction. 

Inflammation 147 

Different  Forms  of  Inflammation 150 

Chapter  III. — General  Reaction. 

Natural  Protective  Sul)stances 155 

Phagocytosis 158 

lOhrlich's  Side-chain  Theory 159 

Antitoxic  and  Bactericidal  Immune  Sera 159 

(  iiAiTKR  IV. — Fever. 

Aseptic  Fever 167 


TABLE  OF  CONTICNTS  ix 

//.     WOUND  INFECTIONS  CAUSED  BY  PYOGENIC  AND  PUTREFACTIVE 
BACTERIA   AND   THEIR  RESULTS 

Chapter  I. — The  Most  Important  Pyogenic  Bacteria.  p^„p 

a,  Staphylococci 17q 

b,  Streptococci I73 

c,  Diplococcus  Pneuinoninj 173 

d,  Micrococcus  Tetragcnus ],S() 

e,  Micrococcus  Gonorrhoja',  G()noc<jccus ],S1 

/,  Bacillus  Pyopyaneus l,t^3 

g,  Bacterium  Coli  Coniniuuc ISO 

h,  Bacillus  Typhosus 188 

Chapter  II. — Infection  Atria  of  Pyogenic  Bacteria 1'J2 

Chapter  III. — Pyogenic  Infections  and  their  Treatment  ....  IDO 

Chapter  IV. — Pyogenic  Infections  of  Different  Tissues. 

a,  Pyogenic  Infections  of  Skin  and  Subcutaneous  Tissues  .        .  202 

Furuncle 2(J2 

Subcutaneous  Abscess 20S 

Subcutaneous  Phlegmon 210 

Erysipelas 213 

Erysipeloid 220 

b,  Pyogenic  Infections  of  Mucous  Membranes        .        .        .        .221 

c,  Pyogenic  Infections  of  Lymphatic  Vessels  and  Nodes      .        .  226 

Lymphangitis 226 

Lymphadenitis ^  .        .        .        .  230 

d,  Pyogenic  Infections  of  Blood  Vessels 233 

Arteritis 233 

Phlebitis •       .  234 

e,  Pyogenic  Infections  of  Bone 236 

Hsematogenous  Sup})urative  Osteomyelitis     ....  238 

Bacterial  Forms 2o6 

Typhoid  Osteomyelitis 257 

Secondary  Osteomyelitis 2o8 

Phosphorus  Necrosis 258 

/,  Pyogenic  Infections  of  Joints 262 

Synovitis '2(V.i 

Arthritis 265 

Bacterial  Forms  (Gonorrhoea,  Pneumonia,  Tyjihoid)    .        .  2(58 

g,  Pyogenic  Infections  of  Tendon  Sheaths  and  Burs;c  272 

h,  Pyogenic  Infections  of  Muscle  and  the  Subfascial  and  Inter- 
muscular Phlegmons 275 

Myositis 275 

Subfascial  and  Intermuscular  Phlegmons       ....  277 

Woody  Phlegmon 277 

i,  Pyogenic  Infections  of  Serous  Cavities  and  DiiTercnt  ^■isccra .  278 

Chapter  V. — General  Pyogenic  Infections. 

a,  General  Pyogenic  Infection  with  Metasta-ses      ....  282 

b,  General  Pyogenic  Infection  without  Metastases        .        .        .  287 

Blood  Examinations  for  Bacteria 2'.)2 

Fever  Curves 292 


PAGE 


X  TABLE   OF  CONTENTS 

Chapter  VI. — Putrefactive  Infections. 

a,  Putrefactive  Wound  Infections  and  General  Infections  .        .  293 

Putrefactive  Bacteria 295 

b,  Allied  Processes 304 

Gas  Phlegmon,  Malignant  CEdema 304 

Noma  (Water  Cancer,  Gangrene  of  the  Cheek)      .        .        .  305 

Hospital  Gangrene 308 

Chapter  VII. — Supplement  to  Treatment  of  Acute  Inflammation. 

Bier's  Passive  Hyperaemia 310 

Treatment  by  Suction  Glasses 314 

Chapter  VIII. — Surgical  Hematology 316 


///.     WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS   AND 
SURGICAL   INFECTIOUS  DISEASES 

Chapter  I. — Wound  Infections  Caused  by  Poisons. 

Snake  Venom 326 

Arrow  Poison,  Cadaveric  Poisons 330 

Chapter  II. — Hydrophobia 331 

Chapter  III. — ^Tetanus 335 

Chapter  IV. — -Diphtheria. 

Diphtheria  of  Mucous  Membranes 348 

Diphtheria  of  Skin 353 

Chapter  V.— Anthrax 354 

Chapter  VI. — -Glanders 361 

Chapter  VII. — Actinomycosis 365 

Chapter  VIII. — Madura  Foot 375 

Chapter  IX. — -Blastomycosis 376 

Chapter  X. — Tuberculosis. 

Local  Surgical  Tuberculosis 403 

a,  Tuberculosis  of  the  Skin 403 

b,  Tuberculosis  of  the  Subcutaneous  Tissues           .        .        .  408 

c,  Tuberculosis  of  the  Muscles 408 

d,  Tuberculosis  of  Mut^ous  Membranes 409 

c,  Tuberculosis  of  Lymi)hatic  Vessels  and  Nodes  .        .        .411 

/,  Tuberculosis  of  Bones 416 

g,  Tuberculosis  of  Joints 428 

h,  Tuberculosis  of  Tendon  Sheaths  and  Bursas      .        .        .  442 

i,  Tuberculosis  of  Serous  Cavities  and  Different  Viscera      .  444 

General  Treatment  of  Local  Tuberculosis 444 

Acute  General  Miliary  Tuljercidosis 445 

ClIAl'TEU  XL — Lei'rosy 

Lepra  Tuborosa 450 

Le|)ra  Maculo-Aniesthetica 452 


TABLE   OF  CONTENTS  xi 

Chapter  XII. — Syphilis.  p^,,p 

(I,  Syphilis  of  the  Skin 4(J0 

b,  Syi)hili.s  of  the  Mucous  McTiibraiin 4G:i 

c,  Syphilis  of  Muscle 40") 

d,  Syphilis  of  Lymphatic  Vessels  tuid  Nodes  Mtid  Hlood  Vessels  .  406 

e,  Syphilis  of  Bone 40'. » 

/,  Syi)hilis  of  Joints 477 

g,  Syjihilis  of  Tendon  Sheaths  and  liursa' 47S 

h,  Syphilis  of  Different  Viscera 47'. t 

Prognosis  and  General  Treatnu-nt 47i) 

Chapter  XIII. — Rhinoscleroma 4S1 

Chapter  XIV. — -Botryomycosis 483 


PART   III 

NECROSIS 


Chapter  I. — Necrosis  the  Result  op  Trauma  (Direct  Action  of,  and 

Following  Injuries  of  Vessels) 488 

Chapter  II. — Necrosis  the  Result  of  Pressure,  Constriction,   Inv.agi- 

nation,  and  Torsion 491 

Chapter  III. — Necrosis  due  to  Thermal  and  Chemical  C.a.use.s. 

Carbolic  Acid  Gangrene 495 

Chapter  IV. — Necrosis  due  to  Thrombosis  and  Embolism   ....  490 
Chapter  V. — Necrosis  due  to  Chronic  Diseases  of  the  Vessels. 

a,  Angiosclerotic  Necrosis 499 

b,  Diabetic  Gangrene 501 

c,  Syphilitic  Gangrene  of  the  Extremities 505 

d,  Circulatory  Disturbances  Following  Dilatation  of  the  Veins  .  506 

Varicose  LTlcers 507 

Chapter  VI. — Necrosis  of  Neuropathic  Origin. 

Raynaud's  Disease 512 

Ergot  Gangrene 513 

Perforating  Ulcer  of  the  Foot 513 

Multiple  Neurotic  Necrosis  of  the  Skin   ......  514 


PART   IV 

INJURIES  OF  SOFT  TISSUES,  BONES,  AND  JOINTS,  AND  THEIR 

TREATMENT 

/.     MECHANICAL  INJURIES 

Chapter  I. — Classification  of  Mechanical  Injuries 516 

Chapter  II. — Mechanical  Injuries  of  the  Different  Tissues. 

(I.)      Injuries  of  the  Skin,  Subcutaneous  Tissues,  and  Mucous  Mem- 
branes    518 


xii  TABLE  OF  CONTENTS 

PAGE 

Large  Hiematoinas 519 

Subcutaneous  Separation  of  the  Skin /)22 

Traumatic  Emphysema      .        .  " 52'.i 

(IL)      Injuries  of  Fascia  and  Muscles 525 

a,  Subcutaneous  Injuries 525 

Muscle  Hernia 525 

Contusion  of  Muscles 525 

Laceration  of  Muscles 526 

b,  Open  Injuries  of  Fascia  and  Muscles 528 

(III.)      Injuries  of  Tendons 529 

a,  Subcutaneous  Injuries 529 

Rupture  of  Tendons 529 

Subluxations  of  Tendons 5.30 

b,  Open  Injuries  of  Tendons 531 

Tendon  Suture 532 

Tenoplasty,  Transplantation  of  Tendons        ....  535 

(IV.)     Injuries  of  Tendon  Sheaths  and  Bursa; 537 

(V.)     Injuries  of  Peripheral  Nerves    ........  538 

a,  Subcutaneous  Injuries 538 

Concussion  of  Nerves 538 

Contusion  of  Nerves 538 

Stretching  and  Laceration  of  Nerves 539 

Subluxation  of  Nerves 540 

b,  Open  Injuries  of  Nerves 541 

Degeneration  and  Regeneration 541 

Nerve  Suture 544 

Neuroplasty  and  Nerve  Grafting 546 

(VI.)     Injuries  of  Vessels 549 

a,  Subcutaneous  Injuries  of  Large  Blood  Vessels  ....  550 

b,  Open  Injuries  of  Large  Blood  Vessels 551 

Secondary  Hsemorrhage,  Air  Embolism          ....  553 

Ligation 555 

Suture  of  Vessels 555 

(VII.)      Injuries  of  Lymphatic  Vessels 557 

(VIII.)     Injuries  of  Joints 559 

u,  Subcutaneous  Injuries 559 

Contusions 560 

Sprains 561 

Joint  Mice 563 

Dislocations 565 

b.  Open  Injuries 569 

(IX.)      Injuries  of  the  Osseous  System 571 

u,  Subcutaneous  Injuries  of  Bone  and  Cartilage    ....  571 

Subperiosteal  Pliematoma 571 

Hicmorrhage  into  Bone  Marrow 572 

Fractures 572 

Different  Forms  of  Fractures 573 

Displacements 577 

Callus  Formation 581 

Pseud  arthrosis 583 

Reduction  of  Fracture 585 


TABLE   OF  CONTENTS 


XIU 


(X.) 
(XL) 


Plaster-of-Paris  Cast  .... 

Extension  Dressing 

Early  Movement  and  Massage 

Osteoclasis 

Reduction  by  the  Open  Method 
b,  Open  Lijuries  of  Bone  and  Cartilage  . 
Injuries  of  Body  Cavities  and  Different  Viscera 
Gunshot  Woinids. 

By  Firearms  of  Small  Calil)er   .... 
By  Artillery 


PAGE 

587 

."),S'.) 

.v.d 

'AKi 

5M9 

600 
G(JS 


//.     CHEMICAL   IX JURIES 
Chemical  Lijuries 


013 


///.     THERMAL   IXJURIES 

Chapter  L — Freezing GIG 

Chapter  IL — Burns. 

Causes  of  Death 627 

Roentgen-Ray  Burns 628 

Lightning  Stroke 628 

Sunstroke  and  Heat  Stroke 029 

IV.     GENERAL   RESULTS   OF   INJURIES 

Chapter   L — Collapse,  Syncope,  Shock     632 

Chapter  IL — Delirium  Tremens 638 

Chapter  III. — Fat  Embolism 640 

Chapter  IV. — Traumatic  Diabetes 642 


PART  V 

IMPORTANT   SURGICAL   DISEASES  EXCLUDING    INFECTIONS 
AND  TUMORS 

Chapter  I. — Diseases  of  the  Skin  and  Mucous  Membranes. 

a,  Congenital  Malformations  of  the  Skin 643 

b,  Eczema 643 

c,  (Edema  of  the  Skin  ami  Mucous  Membrane       ....  645 

d,  Elephantiasis 648 

Rhinophyma ^'^'- 

Chapter  II. — Diseases  of  Muscles  and  Tendons. 

a,  Congenital  Defects  in  Muscular  Development   ....  654 

b,  Atrophy  of  Muscles 654 

Ischsemic  Palsy 65o 

c,  Thickening  and  Ganglion  of  Tendons 656 

Chapter  III. — Diseases  of  Tendon  Sheaths  and  Buus.e. 

Tendovaginitis  Crepitans 657 

Hygroma 6o9 


xiv  TABLE   OF   CONTENTS 

Chapter  IV. — Diseases  of  the  Blood  Vessels  and  Lymphatic  Vessels.  pace 

a,  Arteriosclerosis 661 

b,  Aneurysms 663 

c,  Phlebectases,  Varices 680 

d,  Thrombosis  and  Embolism 685 

c,  Lymphangiectases 691 

Chapter  V. — Disease  op  the  Peripheral  Nerves. 

a,  Neuralgia 693 

h,  Neuritis 697 

Chapter  VL — Diseases  of  the  Joints. 

u,  Dislocations  and  Subluxations 699 

h,  Contractures  and  Anchylosis 702 

Dermatogenous,  Desmogenous  Contractures  ....  702 

Myogenous,  Neurogenous  Contractures 703 

Arthrogenous  Contractures 706 

Anchylosis 706 

Tenotomy 707 

Lengthening,  Shortening,  and  Transjjlantation  of  Tendons  711 

c,  Special  Diseases  of  the  Joints 712 

1,  Synovitis  Chronica  Serosa 712 

2,  Chronic  Articular  Rheumatism 713 

3,  Arthritis.  Osteoarthritis  Chronica  Deformans    .        .        .717 

Joint  Mice 719 

4,  Arthritis  Urica,  Articular  Gout 723 

d,  Diseases  of  the  Joints  in  Haemophilia 728 

e,  Ganglion 730 

Chapter  VIL — Diseases  of  Bone. 

a,  Failure  of  Development 733 

b,  Atrophy  of  Bone 733 

c,  Hypertrophy  of  Bone,  Leontiasis  Ossea,  Acromegaly       .        .  736 

d,  Rickets 738 

^  Barlow's  Disease 746 

e,  Osteomalacia 747 

/,  Bone  Disease  in  Mother-of-Pearl  Workers          ....  750 


PART  VI 

TUMORS 

/.  GENERAL   PART 

Chapter  L — Definition  and  Classification 751 

Chapter  II. — Etiology  of  Tumors 753 

Chapter  III. — Forms,  Growth,  and  Clinical  Sionificance  of  Tumors. 

Recurrence  antl  Metastases 760 

Cachexia 762 

Chapter  IV. — General  Diagnosis  of  Tumors. 

Methoils  of  Examination   . 763 

Examples  in  Diagnosis  of  Tumors 768 

Chapter  V. — Geneical  Tre.vtment  of  Tumors 773 


TABLE  OF  CONTEXTS  xv 


//.    THE   l)[h'FEliENT    VARIETIES   OF   TUMORS 

A.       CoNNKCriVlC-TlSSUK    TUiMUIt.S 

Chapter  I. — Fibromas.  p^^^, 

(I.)     Fibromas  of  the  Skin 780 

a,  The  Soft  Wart 7SU 

b,  Fibromata  Molhi.sca 7Sl 

c,  Lobulated  Elephantiasis 7Sl 

d,  Hard  Fibromas 7.S3 

e,  Keloids 784 

(II.)     Fibromas  of  the  Subcutaneous  Tissues 786 

(III.)     Fibromas  of  the  Mucous  Membranes 789 

(IV.)     Fibromas  of  the  Fascia  and  Aponeuroses 790 

(V.)     Fibromas  of  the  Periosteum 791 

(VI.)     Fibromas  of  the  Glandular  Organs 792 

(VII.)     Fibromas  of  the  Nerves  (Fibromata  Nervorum)    ....  792 

(VIII.)     Fibromas  of  the  Peritoneum 795 

Chapter  II. — Lipomas. 

Diffuse  Symmetrical  Lipomas  .        .        .        .        .        .        .        .  804 

Chapter  III. — Chondromas 805 

Chapter  IV. — Osteomas. 

Cartilaginous  Exostoses 813 

Fibrous  Exostoses 815 

Myositis  Ossificans  Progressiva 818 

Myositis  Ossificans  Circumscripta 820 

Chapter  V. — Angiomas. 

a,  Hsemangioma 822 

Hsemangioma  Simplex 822 

Haemangioma  Cavernosum 825 

Cirsoid  Aneurysm  (Angioma  Arteriale  Raceniosum)     .        .  829 

6,  Lymphangiomas 831 

Lymphangioma  Simi)lex 831 

Lymphangioma  Cavernosum 832 

Lymphangioma  Cysticum 834 

Chapter  VI. — Sarcomas. 

a,  Sarcomas  Developing  from  the  Diiferent  Connective  Tissues  842 

1,  Fibrosarcomas 84.3 

2,  Chondro-  and  Osteosarcomas 851 

6,  Sarcoma  Composed  of  Cells  Resembling  Lymph  Corpuscles   .  8t)3 

1,  Lympho-Sarcoma SG4 

2,  Malignant  Lymphoma 8<>(; 

Multiple  Myeloma,  Chloroma 871 

c,  Sarcomas  Composed  of  Myxomatous  Tissue,  Myxoma     .        .  872 

d,  Sarcomas  Composed  of  Pigment  Cells S7G 

Pigmented  Moles — NiEvi 882 

B.     Tumors  Composed  of  Muscle 

Chapter  I. — Leiomyomas 887 

Chapter  II. — Rhabdomyomas 891 

1 


xvi  TABLE  OF  CONTENTS 

C.     Tumors  Composed  of  Nerve  Elements 

PAGE 

Chapter  I. — Neuromas 894 

Chapter  II. — Gliomas       ; 895 

D.     Tumors  Developing  from  Epithelium 
Chapter  I. — Fibro-epithelial  Tumors. 

a,  The  Group  of  Papillomas 898 

Cutaneous  Horns 900 

b,  The  Group  of  Adenomas 903 

1,  Adenomas  of  the  Skin 903 

2,  Adenomas  of  Mucous  Membranes 905 

3,  Adenomas  of  the  Salivary  Glands 908 

4,  Adenomas  of  Glandular  Organs 908 

c,  The  Group  of  Epithelial  Cysts 912 

1,  Dermoid  Cysts 912 

Epidermoids 913 

2,  Epithelial  Cysts 916 

3,  Cholesteatomas 919 

4,  Adamantinomas 921 

Follicular  Cysts  of  the  Jaws 923 

5,  Epithelial  Cysts   Developing  from  Normal  Embryonal 

Anlage 924 

Chapter  II. — Carcinomas. 

a,  Carcinomas  of  the  Skin 937 

Seborrhea  Senilis 940 

1,  The  Superficial  Carcinomas  of  the  Skin      ,        .        .  941 

2,  Deej?  Carcinomas  of  the  Skin 945 

3,  Papillary  Carcinomas  of  the  Skin        ....  946 

b,  Carcinomas  of  the  Mucous  Membranes 948 

Leukoplakia 949 

c,  Carcinomas  of  Glandular  Organs 957 

d,  Clinical  Course  of  Carcinomas 960 

e,  Endothelial  Tumors 963 

E.  Endotheliomas 

Lymphangio-cndothelioma 963 

Hiemangio-ondothelionia 965 

Perithelioma 965 

Psammoma 967 

Cylindroma 968 

F.  Mixed  Tumors 
Chapter  I. — Simple  Mixed  TuMoits. 

Of  the  Salivary  (Hands 971 

Of  the  Mammary  Glands  . 974 

Of  the  Urogenittd  System 97£ 

Chaptku  II. — The  Tkkatoid  Tumors. 

a,  Complicated  Dermoid  Cysts  of  the  Ovaries  and  Testicles       .  977 

b,  The  Teratoid  Mixed  Tumors 980 

Chapteh  III.— Teratomas 982 


TABLE  OF  CONTENTS 


XV 11 


PART   VII 

CYSTS,    NOT    INCLUUINC;   CVSTIC   Tl'MORS 

Chapter  I. — Exudation  and  Extravasation  Cysts 
Chapter  II. — Liquefaction  Cysts         .... 
Chapter  III. — Dilat.\tion  and  Retention  Cysts. 

a,  Hydrops  Vesicae  Fellse,  Pyosalpinx,  etc 
h,  Retention  Cysts  of  Glands    . 

1,  Sebaceous  Cysts 

2,  Mucous  Cysts  .... 

3,  Cysts  of  Salivary  Glands 

4,  Cysts  of  Glandular  Organs    . 
c,  Lymphatic,  Blood,  and  Chylous  Cysts 

Chapter  IV. — Parasitic  Cysts. 

a,  Echinococcus 

h,  Cysticercus  Cellulosse     .... 


PAGE 

986 

987 

988 
988 
989 
991 
993 
993 
994 


995 
10U2 


APPENDICES 

Appendix  I. — Direct  Transfusion  of  Blood 1007 

Appendix  II. — Opsonins,   Phagocytosis,   and   Therapeutic  Inoculations  of  Dead 

Bacteria 1011 


INDEX 


1019 


LIST   OF   COLOKED   PLATES 


FACING 
PAOE 

PLATE  1 884 

Fig.  1.     Flat  Pigmented  N^evus. 

Fig.  2.     Alveolar  Melanoma  of  the  Skin. 

Fig.  3.     Mixed  Tumor  of  the  Parotid  Gland. 

PLATE  IL     LATERAL  BRANCHIAL  FISTULA 926 


LIST   OF   ILLUSTRATIONS 


FIGURE  PACK 

1. — Directions  of  the  Tension  Planes  of  the  Skin 2 

2. — Digital  Pressure  on   Femoral 6 

3. — Digital  Compression  of  the  Brachial  against  the  Bone 6 

4. — Elastic  Bandage 7 

5. — Elastic  Bandage  Applied 7 

6. — Martin's  Bandage 7 

7. — Paquelin's  Thermo-Cautery 0 

8. — Forceps,  Serre-fine 10 

9. — Ligation  by  Transfixion 10 

10. — ^Tying  Ligature  after  Transfixion 11 

IL — Passing  of  Ligature  beneath  Artery  with  Aneurysm  Xecille    .        .        ,        .  11 

12. — Torsion  of  an  Artery 12 

13. — Interrupted  Suture 22 

14.— Elevation  of  Edge  of  Woiuid  with  Rat-tooth  Forceps  while  Passing  Suture  22 

15,  16. — Suture  Inserted  Improperly 23 

17a,  17b,  and    18. — Suture  Passed  Properly 23 

19,  20,  21,  and  22.— Tying  Sutures 24 

23. — Continuous  Suture  Uniting  Stomach  and  Intestine 25 

24. — Mattress  Suture 25 

25.— Hals  ted 's  Subcuticular  Stitch 25 

26.— Quilled  Suture 26 

27.— Leaded  Suture 26 

28.— Twisted  Suture -<' 

29.— Intestinal  Suture -^ 

30.— The   Internal  Continuous   Suture   Imcrted   by   an   External   Interrupteil 

Layer -' 

xix 


XX  LIST    OF   ILLUSTRATIONS 

FiocRE                                                                                                                                                                             pa<;e 
3L — Gangrene  of  the  Great  Toe,  following  Ai)2)lication  of  Carbolio  Acid  (Join- 
press       ."JO 

32. — Rubber  Drainage  Tube,  Thread  Fastening 32 

33. — Rubber  Drainage  Tube,  Pin  Fastening 32 

34. — Isolated  Cells  from  Granulation  Tissue 36 

35. — Healing  of  a  Sutured  Incisecl  Wound  of  the  Skin  Six  Days  Old      ...  37 

36. — Section  from  a  Scar  in  the  Skin  Twenty-six  Days  Old 37 

37. — Section  from  Wound  Four  Days  Old,   Following  Am])utation  of  a  Dog's 

Tongue 40 

38.— Section  Through  the  Edge  of  a  Granulating  Incised  Wound  About  Three 
Weeks  Old,  Surrounding  a  Fistula  Leading  to  an  Osteomyelitic  Focus 

in  the  Femur 41 

39. — Section  of  Granulation  Tissue  Removed  from  an  Abscess  Membrane  Sur- 
rounding a  Suppurating  Focus  in  Bone 42 

40. — Margin  of  a  Skin  Defect  Following  the  Removal  of  Epidermal  Strijjs  for 

Skin-grafting 43 

41. — Bone  Formation    at    the    Margin    of    Medullary  Cavity  and  About    the 

Haversian  Canals 48 

42. — Lead  Box  with  Trays  for  Brushes  for  Sterilization  in  Steam  ....  54 

43. — Schimmelbusch's  Apparatus  for  Sterilizing  Instruments          ....  61 

44. — Kny-Scheerer  Sterilizing  Pan  with  Instruments  for  Use  in  Steam  Sterilizer  61 
45. — Instrument  Table  on  which  Sterile  Instruments  Required  for  Immediate 

Use  are  Placed 62 

46. — Can  for  Sterilization  of  Dressings  and  Sponges 64 

47. — a.  Pressure    Steam    Dressing    Sterilizer;     b.  Combination    Sterilizing    Ap- 
paratus   64,  65 

48. — Glass  Ironer  for  Gauze 67 

49. — Canvas  Bag  for  Carrying  Supplies  which  may  be  used  in  Private  Practice   .  80 

50. — Canvas  Bag  for  Carrying  Supi^lies  which  may  be  used  in  Private  Practice    .  81 

51. — ^The  Chloroform  Mask  of  Schimmelbusch 92 

52. — Heister's  Mouth  Gag;  the  Koenig-Roser  Mouth  Gag 92 

53. — Junker's  Apparatus  as  Modified  by  Kappeler 93 

54. — Pushing  the  Lower  Jaw  Forward 95 

55. — Salzer's  Chloroform  Canula 96 

56. — Chloroform  Apparatus  for  Administering  an  Anaesthetic  Through  a  Tra- 
cheotomy Tube 97 

57.— Cloth  and  Paper  Cone 100 

58.— Allis's  Inhaler 101 

59.— Ether  Mask  after  Julliard  (I)umont) 101 

60. — Gradual  Ai)plication  of  Mask  to  Face 101 

61. — Lifting  the  Mask  to  Inspect  Face  and  Permit  of  Free  Access  of  Air     .        .  102 

62.- — -Surrounding  the  Mask  with  a  Towel 103 

63.— Bennett's  lather  Inhaler 103 

64. — Bennett's  Nitrous  Oxid  Inhaler 105 

65,  66. — Showing    Inversion   of   Patient   nnd    Method   of   Performing   Artificial 

Respiration  Simultaneously 110,  111 

67.— Chlorid  of  Ethyl 119 

68. — Syringe  Holding  10  or  15  c.c.  which  may  be   Used  for  Injecting   Cocain 

Solution 121 

69. — Infiltration  of  Dec))  Layer  of  Skin 121 

70. — Infiltration  Ana-sthcsia 121 


LIST   OF    ILLl'STRATIOXS  XXl 

FIGURE  pAtiK 

71. — Matas  Apparatus,  Introikicing  the  Air 122 

72,73. — Approximation  of  the  Edges  of  a  Wound  by  "Undercutting"         .        .  127 
74,  75,  76. — Approximation  of  the  Edges  of  a  Wound  by  "Undercutting"  .        .128 

77,  78,  79,  80. — ^Approximation  of  the  Edges  of  a  Wound  by  "  Undercutting"    .  129 

81. — Approximation  of  the  Edges  of  a  Wound  by  "Umlercutting"        .        .        .  130 

82,  83. — Covering  of  the  Defect  by  Flaps  taken  from  an  Adjacent  Area        .        .  130 
84. — Covering  of  the  Defect  liy  Flaps  taken  from  an  Adjacent  Area      .        .        .131 

85. — Displacement  of  Peduncidated  Flap  upon  Pedicle 132 

86. — Cutting  Grafts;   Traction  Hooks 135 

87. — Cutting  Grafts  Without  Traction  Hooks  and  Placing  Grafts  in  Position      .  136 

88. — Section  of  Inflamed  Omentum  from  Man 147 

89. — Staphylococci 170 

90. — Streptococci 174 

91. — Pneumococci 178 

92. — Micrococcus  Tetragen us 181 

93. — Gonococci 181 

94. — Bacillus  Typhosus 189 

95. — ^Section  Through  Tonsillar  Crypt  of  a  Ral)bit  I>yiiig  of  a  General  Bacterial 

Infection 194 

96. — A  Felon  of  the  Index  Finger 198 

97. — Large  Carbuncle  of  the  Neck  Developing  from  a  Furuncle      ....  205 

98. — The  Same  Case  Eight  Days  After  Operation 206 

99. — The  Same  Case  Four  Weeks  After  Operation 207 

100. — The  Internal  Layer  of  an  Abscess  Membrane  Composed  of  Granulation 

Tissue 209 

101. — Suppurative  Osteomyelitis  of  the  Tibia  (Semidiagrammatic)          .        .        .  237 

102. — Tubular  Sequestrum 238 

103. — Total  Necrosis  of  the  Humerus 238 

104. — ^Total  Necrosis  of  the  Humerus  as  Seen  in  a  Roentgen-Ray  Picture      .        .  239 
105. — Tibia  of  a  Yoimg  Rabbit  with  a  Total  Sequestrum  of  the  Diaphysis     .        .241 
106. — ^Femur  of  a  Child  Four  Weeks  Old,  the  Vessels  of  which  have  been  In- 
jected, as  Seen  in  a  Roentgen-Ray  Picture 242 

107. — Foci  of  Staphylococci  in  the  Neck  of  the  Femur,  Intracapsular  Rupture     .  246 
108. — Pneumococcic   Focus   in    the    Internal    Malleolus,    Rupture   Through    the 

Epiphysis 247 

109. — Pneumococcic  Focus  in  Lower  Articidar  End  of  the  Femur  or  a  Child          .  247 
110. — ^Severe  Osteomyelitis  of  the  Femur  in  a  Child  Nine  Weeks  Old      .        .        .  248 
111. — Suppurative  Inflammation  of  the  Elbow  Joint,  Secondary  to  Osteomye- 
litis of  the  Ulna 249 

112. — Central  Sequestrum  in  the  Lower  Third  of  the  Radius  of  .Man  Fifty  Years 

of  Age 251 

113. — Necrosis  of  the  Tibia  with  Numerous  Cloacae  l']xposed  for  Se(iuestrotomy     .  253 
114. — Incision  for  Exposure  and  Partial  Removal  of  the  Tibia  hi  Extensive  Su[)- 

purative  Osteomyelitis 254 

115. — Radioflexion  of  the  Hand  following  Destruction  of  the  Lower  Epiphysis 

of  the  Radius  by  a  Suppurative  Osteomyelitis 255 

116. — Marked  Curvature  of  the  Tibia  Resulting  from  Shortening  of  the  Diseased 

Fibula 2.56 

117. — Tyi^hoid  Focus  in  a  Costal  Cartilage 257 

118. — Phosphorus  Necrosis  of  the  Manilible,  after  Haeckel 259 

119. — a.  Osteomyelitis  of  the  Femur;  b.  Specimen  Prepared  after  Amputation     .  267 


xxii  LIST   OF   ILLUSTRATIONS 

FIGURE  PAOE 

120. — Bony  Anchylosis  of  the  Knee  Joint   in  the  Valgus  Position  Following  a 

Gonorrheal  Arthritis 209 

121. — Cicatricial  Contracture  of  the  Thumb 273 

122. — Infection  Forming  Metastases 288 

123. — General  Pyogenic  Infection  without  Metastases 289 

124. — Infection  Forming  Metastases  with  Transition  into  a  General  Blood  In- 
fection     290 

125. — Infection  Forming  Metastases  Following  a  Carbuncle  of  the  Upper  Lip      .  291 

126.— Absorption  Fever 292 

127. — Noma  in  a  Chinaman  Sixteen  Years  of  Age 306 

128. — Picture  Taken  on  Sixteenth  Day  of  the  Disease  After  Cauterization     .        .  306 

129. — Deformity  Following  a  Noma  of  the  Face,  which  Healed        ....  307 
130. — Band  Producing  Passive  Hypersemia  Applied  to  the  Arm       .        .        .        .311 

131. — Suction  Apparatus  for  Mastitis 314 

132. — Suction  Apparatus  for  Felons 314 

133. — Suction  Glass  for  a  Furuncle 315 

134.— Tetanus  Bacilli 336 

135.— Diphtheria  Bacilli 346 

136. — Section  Through  the  Uvula,  from  a  Case  of  Pharyngeal  Diphtheria      .        .  350 

137.— Anthrax  Bacilli 355 

138.— Anthrax  Carbuncle 358 

139. — Section  Through  (a)  a  Fully  Develoj^ed  Colony,  and  Section  Through  (h) 

a  Degenerated  Colony 365 

140. — Actinomyces 366 

141. — A  Piece  of  Grain  Covered  with  Colonies  of  Ray  Fungi  Removed  from  an 

Actinomycotic  Swelling  in  the  Tongue  of  an  Ox 368 

142. — Hsematogenous  Osteomyelitis  of  the  Femur  Caused  by  the  Ray  Fvnigus      .  369 

143. — Actinomycosis  of  the  Face  and  Neck 370 

144. — Actinomycosis  of  the  Neck 371 

145. — Cutaneous  Blastomycosis  Showing  Delicate  Scar  Tissue  in  the  Center  with 

Active  Advancing  Border 378 

146. — Cutaneous  Blastomycosis  Showing  Circular  Patch  with"  Papillomatous  Ele- 
vations Covering  the  Surface 379 

147. — Cutaneous  Blastomycosis  Showing  Patch  on  Dorsum  of  Foot         .        .        .  380 

148. — Cutaneous  Lesions  in  a  Patient  the  Subject  of  Generalized  Blastomycosis  .  381 
149. — Microphotograph.     Cutaneous  Section  (High  Power),  Showing  Giant-Cell 

Containing  Organisms  of  Blastomycosis 384 

150. — Cut  Section  of  the  Spleen,  Showing  Areas  of  Blastomycotic  Infiltration      .  385 

151. — Smear  from  Tuberclelike  Lesion  in  the  Spleen 387 

152. — Growth  of  the  Organism  of  Blastomycosis  on  Glycerin-agar,  from  a  Miliary 

Abscess  in  the  Spleen 388 

153. — Smear  from  Growth  of  the  Organism  on  Media  Five  Weeks  Old    .        .        .  389 

154. — ^Tubercle  Bacilli  in  Fresh  S^Dutum 394 

155.— Section  Through  a  Tubercle 400 

156. — Tuberculous  Giant-Cells  Containing  a  Few  Tubercle  Bacilli    ....  401 

157.- — Tuberculous  Abscess  Membrane 402 

158. — Lupus  Exulcerans  and  Kxfoliativus  Faciei 404 

159. — (kitiineous  Tuberculosis  (l^upus  Faciei) 405 

160. — IIyi>ertrophic  and  IHcerating  Lupus 406 

161. — Papillary  Tuberculosis  of  the  Skin 407 

162. — Tuberculous  Ulcer  Over  a  Diseased  Rib 409 


LIST   OF   ILLUSTRATIONS  xxui 

FIGURE  p^OE 

163. — Group  of  Tuberculous  Lyiiii)h  Nodes  Roinoved  by  Operation         .        .        .412 

164. — Incised  Lymph  Nodes,  Showing  Softened  Caseous  F'oci 4i;i 

165. — IHustrating  the  Condition  which  was  Fonncrly  Known  as  Scrofula       .         .  41.5 

J  66. — Femur  and  Tibia  of  a  Four  Weeks' Old  Child 417 

167. — Humerus  of  a  New-born  Child 418 

168. — Metatarsal  Bone  of  the  Thumb  of  a  New-born  Clii id 418 

169. — Thoracic  Vertebra  of  a  Four  Weeks'  Old  Chikl 418 

170. — Vessels  in  the  Os  Innominatum  of  a  New-born  Child 420 

171. — Tuberculous  Caries  of  the  Rim  of  the  Acetabulum 421 

172. — a.  Tuberculosis  of  the  Right  Shoulder  Joint;    b.   Resected   Head   of  the 

Humerus 422 

1  73. — Tuberculosis  of  the  Diaphysis  of  the  Tibia  of  an  Kight-Year-Old  Girl  .        .  422 
174. — Tuberculous   Osteitis   of   the   First   and   Second   Phalanges  of   the   Intlex 

Finger,  with  Abscess  Formation .        .  423 

175. — Tuberculous  Osteitis  of  the  Proximal  Phalanx  of  the  Index  Finger    .        .  423 
176. — Tuberculous  Caries  of   the  Twelfth  Thoracic,  First  and  Second  Lumbar 

Vertebrae 424 

1 77. — Proliferation  of  the  Synovial  Villi  in  Tuberculosis  of  the  Ivnee  Joint     .        .  430 
178. — Tuberculosis  of  the  Knee  Joint  (Resection  Prei>aration)          ....  431 
179. — Coronal  Section  of  the  Lower  Entl  of  a  Femur,  which  was  Amputated  Be- 
cause of  Extensive  Tuberculosis  of  the  Knee  Joint       ....  432 
180. — Section  of  the  Femur  Involved  in  Tuberculosis  of  the  Knee  Joint         .        .  433 

181. — Tuberculous  Hydrops  of  the  Right  Knee 435 

182. — Tuberculosis  of  the  Left  Knee  (Granulating  Form,  Fungus)           .        .        .  436 
183. — Tuberculosis  of  the  Elbow  Joint  (Granulating  Form  with  Abscess  Forma- 
tion)         437 

184. — Tuberculosis  of  the  Ankle  Joint  (Granulating  Form  with  Fistulse)        .        .  437 

185. — Healed  Tuberculosis  of  the  Knee  Joint 438 

186. — Tuberculosis  of  the  Tendon-sheath  of  the  Flexor  Tendons  of  the   Index 

Finger  (Granulating,  Cicatrizing  Form) 443 

187. — Bacilli  of  Leprosy  in  the  Skin 448 

188. — Lepro.sy  Bacilli  in  the  Mucous  Membrane 449 

189. — Leprosy  Bacilli  in  Nerves 449 

190. — Lepra  Tuberosa 450 

191. — Lepra  Maculo-ana>sthetica 452 

192.— Spirocha?ta  Pallida 454 

193. — ^An  Ulcerated  Chancre  Ten  Days  Old 455 

194. — Ulcerated  Gununa  with  Scalloped  Borders  due  to  Unecpial  Cicatrization      .  459 
195. — Papulo-serpiginous  Syphilide  of  the  Skin  of  the  Forehead       .        .        .        .461 

196.— A  Thirty- Year-Old  Woman  Infected  with  Sji^hili-^ -l^j- 

197. — Sji^hilitic  Hj'perostosis  of  the  Tibia 468 

198. — Syjihilitic  Periostitis  of  the  Radius.     Congenital  Syphilis        ....  469 

199. — Large  Syphilitic  Ulcers  of  the  Head 470 

200. — Gummatous  Periostitis  and  Osteitis  with  Necrosis 471 

201.— Syphilitic  Saddle-Nose 472 

202. — Defect  in  the  Skull  caused  by  Gummatous  Osteomyelitis        .        .        .        .473 

203.— Congenital  Syphilitis  Dactylitis 473 

204.— Pathological  Fracture  of  the   Shaft  of  the  Radius 474 

205.— Syphilitic  Osteitis  Defonnans  with  Roontgen-Ray  Picture      ....  475 
206. — Necrosis   (Dry  Gangrene)   of  the  Arm   Following  Rupture  of  a   Diseased 

Axillary  Artery ^^^ 


xxiv  LIST   OF    ILLUSTRATIONS 

FIGURE                                                                                                                                                                       .  PARE 

207. — Roentgen-Ray  Picture   Showing  Arteries  of   the   Foreurin   :in<l   Hand   in 

Advanced  Arteriosclerosis •')00 

208.— Diabetic  Gangrene •')()2 

209. — Varicose  Ulcer  of  the  Leg .'')07 

210. — Syphilitic  Ulcer  of  the  Leg 508 

211.= — Decubitus  in  a  Paralytic  Club  Foot,  Associated  with  a  Spina  Bifida  Oc- 
culta with  Hyjiertrichosis 511 

212. — Perforating  Ulcer  of  the  Foot  in  Locomotor  Ataxia 513 

213. — -Tendon  Suture  According  to  Friedrich 533 

214. — (o)  Tendon  Suture  According  to  Woefler;  (b)  According  to  Hicgler;  (c-f) 

According  to  Trnka 534 

215. — Tenoplasty  (a)  Hueter  Method,  Single  Flap;  (b)  Gluck's  Method,  Catgut 

Repair 535 

216.— Tenoplasty,  Single-Flap  Method 535 

217.— Tenoplasty,  Double-Flap  Method 535 

218. — Tenoplasty,  Poncet's  Accordion  Method 536 

219. — Tenoplasty,  Incision  Method 536 

220. — ^Tenoplasty,  Tendon  Lengthened  in  Incision  Method 536 

221. — Lengthening  of  Tendons 536 

222. — Secondary  Nerve  Suture  According  to  Von  Bruns 546 

223. — Suture  of  the  Pointed  Peripheral   End  of  the  Nerve  into   the  Proximal 

End 546 

224. — Different  Forms  of  Bending  Fractures 574 

225. — Spiral  Fracture  of  the  Femur  with  a  Tyjiical  Screw-shaped  Fragment          .  575 

226. — Beely's  Molded  Plaster-of-Paris  Dressing  for  Fractures  of  the  Leg        .        .  588 

227.^ — Buck's  Extension  Combined  with  Volkmann's  Sliding  Splint          .        .        .  590 

228. — Supracondylar  Fracture  of  the  Humerus,  I^sual  Type 591 

229. — Destruction  of  the  Elbow  Joint  by  a  Lead-Pointed    (Dum-dum)  Bullet 

Discharged  at  Close  Range 601 

230.— Roentgen-Ray  Picture  of  Fig.  229 602 

231. — Fractures  of  the  Diaphysis  of  the  Humerus  caused  by  a  Jacketed  Bullet  .  605 

232.— Gunshot  Wound  of  the  Lower  End  of  the  Right  Humerus  (1866)          .        .  606 

233. — Comminuted  Fracture  of  the  Tibia 607 

234.— Gunshot  Wound  of  Head  of  the  Humerus  (Battle  of  Duppel,  1848)      .        .  607 

235. — Injuries  of  the  Face  Caused  by  Caustic  Soda 614 

236. — Hypertrophic  Scar  of  the  Forearm  and  HaJid 623 

237. — Scar  Approximating  the  Chin  and  Chest  which  Followed  the  Healing  of  a 

Burn  Produced  by  Boiling  Water 624 

238. — Cicatricial    Adhesions    Between    the   Arm,  Thorax,   and    Back  Following 

Scalding 625 

239. — Tracing  Indicating  the  Fall  in  Blood  Pressure  Associateil  with  Shock  In- 
duced in  Animals  by  Irritation  of  an  Iiiflam('<l  Pleura  and  the  Effect 

of  Adrenalin  Injected  Intravenously 63? 

240. — Elephantiasis  of  the  Loft  Lower  l*L\tremity  in  a  Woiuan  Fifty  Years  Old      .  649 

241. — I'jlephantiasis  of  the  Scrotum 051 

242. — Rhinoi)hyma 652 

243. — Ischaunic  Muscular  Paralysis  and  Contracture 655 

244. — Hygroma  Bursa?  Olecraiii 659 

245. — Hygroma  Bursa-  Olecrani 660 

246. — Ilygronui  Bursa;  Pra-patellaris 661 

247. — Sclerotic  Arteries  as  They  A2)pear  in  a  Roentgen-Ray  Picture       .        .        .  662 


LIST   OF   ILLUSTRATIONS  XXV 

FKUIRK  PAGE 

248. — Fusiform  Aneurysm  of  the  Popliteal  Artery  and  Longitudinal  Section  of 

the  Same  Preparati(jn f^filj 

249. — (a)  The  Three  Principal  Forms  of  Arteriovenous  Aneurysm;   (h)  Special 

Forms CCn 

250. — The  Interior  of  a  Fusiform  Aneurysmal  Sac,  Showing  Openings  and  (Iroove 

of  Main  Vessel  and  Opening  of  Collateral  Jiranch          ....  672 

2.51. — The  Fusiform  Aneurysm.  The  First  Row  of  Sutures  Closing  the  Orifices  .  073 
252. — The  Fusiform  Aneurysm.     The  Second   Row   of  Sutures,   Internii)tcd  or 

Continued      . (174 

253. — ^The  Fusiform  Aneurysm.  The  Second  How  of  Sutures  (Continuous)  In- 
troduced          (",74 

254. — The  Fusiform  Aneurysm.  The  Deep  Supporting  Sutures  in  Place  .  .  675 
255. — -The  Sacciform  Aneurysm,  Its  Main  Office  and  the  Dotted  Outline  of  tlic 

Main  Vessel (i7(} 

256. — The  Sacciform  Aneurysm.     The  Closure  of  Main  Orifice  hy  Continuous 

Sutures 676 

257. — The   Sacciform  Aneurysm.     Closure  of  the   Main   Orifice  by   Interrupteil 

Sutures 677 

258. — The  Sacciform  Aneurysm.  Obliteration  of  Orifice  Completed  .  .  .  678 
259. — ^The  Sacciform  AneuryoUi  with  Catheter  Introduced  to  Maintain  Caliber 

of  Lumen;  Sutures  Over  Catheter 678 

260. — ^The  Sacciform  Aneurysm.     The  Removal  of  Catheter  Before  Final  Closure 

of  the  Main  Channel 679 

261. — Resected  Piece  of  the  Long  Saphenous  Vein 681 

262. — Varicose  Veins  of  the  Lower  Extremity 682 

263. — Dieffenbach's  Tenotome  and  Subcutaneous  Tenotomy  of  the  Tendo  Achillis  708 

264. — Anderson's  Double-flap  Method 709 

265. — -A.  Poncet's  Accordion  Method 71 U 

266. — Incision  Method 710 

267. — ^Tendon  Lengthened  in  Incision  Method 710 

268. — Lengthening  Tendo  Achillis 710 

269.— Plication  of  a  Tendon 711 

270. — Chronic  Arthritis  of  the  Joints  of  the  Fingers 715 

271. — Free  Bodies  Removed  from  a  Knee  in  a  Case  of  Arthritis  Deformans  .        .  720 

272. — Arthritis  Neuropathica  (Tabica)  of  the  Right  Knee  and  Ankle  Joints  .        .  721 

273. — Roentgen-Ray  Picture  of  Case  Represented  by  Preceding  Figure  .        .        .  722 

274. — Pathological  Changes  in  ElboAV  Joint  in  a  Case  of  Syringomj'elia  .  .  .  723 
275. — Arthritis  Urica  (Gout)  Involving  the  Interphalangeal  Joints  of  the  Little 

Finger    . 724 

276. — Ganglion  of  the  Dorsum  of  the  Foot 731 

277. — Leontiasis  Ossea 737 

278. — Coronal  Section  Through  the  Lower  End  of  the  Femur  of  a  Child  SulTcring 

with  Rickets 740 

279. — Genu  Valgum  Adolescentium 741 

280.— Rickets 743 

281. — X-Ray  Picture  of  Deformed,  Rachitic  I^ones  of  the  Leg          ....  745 

282. — Gynsecomastia  (Right  Side),  Male  Patient  Eighteen  Years  Old      .        .        .  766 

283. — Hard  Fibroma  with  Few  Vessels 779 

284. — Fibromata  Mollusca  of  the  Skin  and  Sarcoma  of  the  Left  Axillary  Fossa   .  7S0 

285. — Lobulated  Elephantiasis 781 

286.— Fibroma  Pendulum 782 


xxvi  LIST   OF   ILLUSTRATIONS 

FIGURE  PAGK 

287. — Fungiform,  Hard  Fibroma  of  the  Skin  with  Section  of  the  Same  .        .        .  783 

288. — Fibroma  of  the  Skin,  with  a  Broad  Base,  as  it  Appears  upon  Section  .  784 

289. — Keloid  which  Developed  upon  the  Forearm  of  a  Child  After  a  Scald,  and 

Section  Through  the  Same 785 

290. — Keloid  Developing  in  a  Laparotomy  Woimd 786 

29L — A  Keloid  which  Developed  in  a  Sutured  Woimd  of  the  Arm  After  the  Kx~ 

cision  of  a  Keloid 787 

292. — Recurrence  After  Excision  of  a  Spontaneous  Keloid 788 

293. — Another  Recurrence  After  Four  Years 789 

294. — Fibroma  of  the  Internal  Oblique  Muscle  of  the  Abdomen  in  a  Female  Patient  790 

295. — Fibrous  Naso-pharyngeal  Polyp  which  has  Invaded  the  Antrum  of  Highmore  791 

296. — The  Same  Tumor  Showing  Invasion  of  the  Skull  Cavity         ....  792 
297. — Nerves  Dissected  Free  from  a  Subcutaneous  Plexiform  Neuroma  Removed 

from  the  Occipital  Region  of  a  Child 793 

298. — Plexiform  Neuroma  of  the  Subcutaneous  Nerves  of  the  Thorax  in  a  lioy   .  794 

299. — Large  Fibroma  Removed  from  the  Mesentery  of  a  Male  Patient    .        .        .  795 

300. — Extirpated  Subcutaneous  and  Intermuscular  Lijjoma 797 

301. — Section  of  a  Subcutaneous  Fibrolipoma  of  the  Gluteal  Region       .        .        .  797 

302. — Subcutaneous  Lipoma  of  the  Arm 798 

303. — -Subcutaneous  Lipoma  in  the  Region  of  the  Hip 799 

304. — Subcutaneous  and  Partly  Intermuscular  Lipoma  of  the  Back         .        .        .  800 

305. — Subcutaneous  Lipoma  which"  has  been  Growing  Gradually  for  Fifteen  Years  800 

306. — Lipoma  of  the  Forehead 801 

307. — DifTuse  Symmetrical  Lipomas 803 

308. — Multiple  Enchondromas  of  the  Bones  of  the  Hand    ......  805 

309. — Enchondroma  of  the  Thumb 805 

310. — Roentgen-Ray  Picture  of  a  Cortical  Enchondroma 806 

311. — Enchondroma  of  the  Second  Metacarpal  Bone,  Externally  and  upon  Sec- 
tion          806 

312. — Cystic  Enchondroma  of  the  Seai)ula  of  an  Adidt 807 

313. — Cystic  Enchondroma  of  the  Upper  Metaphysis  of  a  Chikl,  Healed  by  Curet- 
ting          808 

314. — Bone  Cysts  in  the  Humerus  of  a  Boy  Fourteen  Years  of  Age         .        .        .  809 
315. — Enchondromas  of  the  Upper  Metaphyses  of  Both  Bones  of  the  Thigh       .        .810 
316. — Enchondromas  and  Exostoses  of  the  Lower  Ends  of  the  Bones  of  the  Fore- 
arms         811 

317. — Cartilaginous  Exostosis  of  the  Femur 813 

318. — Cartilaginous  Exostosis  of  the  Proximal  Phalanx  of  the  Third  Finger  .        .  814 
319. — Cartilaginous  Exostosis  of  the  Medial  Side  of  the  Upper  Metaphysis  of  the 

Tibia 815 

320. — Multiple  Cartilaginous   Exostoses  of   the   Metaphysis  of   the   Femur  and 

Tibia 816 

321. — Subungual  Exostosis 817 

322. — Enormous  Exostosis  of  the  Temporal  Jione 817 

323. — Progressive  Ossifying  Myositis 819 

324. — Hajmangioma  Simplex  Cutis 823 

325.— Simple  Cutaneous  and  Subcutaneous  HaMnangioma 824 

326. — ^Simple  Lobulatod  Ha^mangioma 825 

327. — Cavernous  Ihcmangioma  of  the  Subcutaneous  Fat 826 

328. — Cavernous  Ha-maiigioma  of  the  Ear 826 

329. — Cirsoid  Aneurysm  of  the  Face ' 829 


LIST   OF    ILLUSTRATIONS 


xxvu 


ork) 


)a  rat  ion) 


FIGURE 

'.V.iO. — Cirsoid  Aneurysm  of  the  Hand  and  Forearm 
IVAl.- — Racemose  Ila^mangioma  of  the  Scalp  .... 

332. — MacromeHa  Caused  by  a  Congenital  Cavernous  Lymphangio 
333. — Congenital  Cavernous  Lynii)haiigioma  of  the  Ear     . 
334. — Lymphangioma  of  the  Tongue  (Macroglossia),  Magnified 
335. — Cystic  and  Cavernous  Lyniijhangioma         .... 
33fi. — Congenital  Cystic  Lymphangioma  (("ystic  Hygroma  of  the  N 
337. — Specimen  Removed  from  Patient  Represented  in  Fig.  336 

338. — Fibrosarcoma 

339. — Large  Spindle-cell  Sarcoma 

340. — Round-cell  Sarcoma  of  the  Skin 

34L — Soft,  Vascular  Sarcoma  of  the  Left  Half  of  the  Face 
342. — Sarcoma  Tissue  which  has  Invaded  Muscle 

343. — Round-cell  Sarcoma  of  the  Cheek 

344. — Sarcoma  of  the  Skin  of  the  Thigh  in  a  Woman 
345. — Fibrosarcoma  of  the  Aponeurosis  of  the  Occipitofrontalis 
346. — Multiple  Sarcomas  of  the  Skin  in  a  Man     .... 
347. — Fibrosarcoma  with  Giant-cells  (Ejjulis)       .... 

348. — Very  Vascular  Sarcoma  of  the  Skin 

349. — Round-cell  Sarcoma  of  the  Skin 

350. — Section  of  a  Pedunculated  Sarcoma  of  the  Skin 

35L — Ulcerated  Round-cell  Sarcoma  of  the  Stomach 

352. — Small  Round-cell  Sarcoma  of  the  Hand,  Developing  from  th( 

353. — Soft,  Small,  Spindle-cell  Sarcoma  of  the  Fascia  Lata 

354. — Central  Giant-cell  Sarcoma  of  the  tapper  Jaw  (Resection  Pre 

355. — Giant-cell  Sarcoma  of  the  Mammary  Gland 

356. — Periosteal  Osteosarcoma  of  the  Ulna 

357. — Periosteal  Osteosarcoma  of  the  Lower  End  of  the  Femur 

358. — Cystic  Osteosarcoma  of  the  Sternum 

359. — Myelogenous  Sarcoma  of  the  Lower  End  of  the  Femur    . 
360. — Osteoid  Sarcoma  of  the  Patella  (Sagittal  Section)     . 

36 L— -Osteosarcoma  of  the  Femur 

362. — Myelogenous  Giant-cell  Sarcoma  of  the  Lower  End  of  the  R 

363.^ — Central  Osteosarcoma  of  the  Fenuir 

364. — Osteosarcoma  of  the  Tapper  End  of  the  Humerus 

365. — Preparation  from  the  Same  Case  Seen  from  Uehind 

366. — Soft,  Spindle-cell  Sarcoma  of  the  Upper  Ei^iphysis  of  the  Humerus 

367. — Section  of  a  Lymphosarcoma  of  the  Nasal  Mucous  Membrane 

368. — Lymphosarcoma  of  the  Neck 

309. — Lymphosarcoma  of  the  Neck  and  Left  Axillarj^  Fossa     . 

370. — Lymphosarcoma  of  the  Neck 

37L — Malignant  Lymphoma 

372. — Myxosarcoma  

373. — Myxosarcoma  of  the  Fascia  Lata 

374. — Myxosarcoma  of  the  Fascia  of  the  Arm 

375. — Myxoma  of  the  Radial  Nerve  in  a  Man  Thirty-five  Years  of  Age  . 
376. — Retroperitoneal    Myxosarcoma   and    Intermuscular   Myxosarcoma   o 

Gluteal  Region 

377. — Melanosarcoma  of  the  Foot  in  a  Man 

378. — Melanosarcoma  of  Foot  in  a  Woman 

379. — Melanoma  of  the  Tip  of  the  Finger 


.liu.s 


the 


pai;e 

830 
8.30 
83.3 
8;{3 
8.33 
8.34 
835 
836 
838 
8.39 
840 
841 
842 
843 
844 
845 
845 
846 
846 
846 
847 
847 
848 
849 
849 
S.")0 
851 
852 
852 
853 
85,3 
854 
854 
855 
856 
857 
858 
864 
865 

sot) 

807 
869 
872 
873 
874 
874 

875 
877 
877 
878 


XXVlll 


LIST   OF   ILLUSTRATIONS 


FIGURE 

380. — Metastases 

381. — Melanotic  Nodule  in  the  Subcutaneous  Fat 

382. — Nsevus  Pigmentosus  Pilosus 

383. — Naevus  Pigmentosus  Verrucosus 

384. — Congenital  Hairy  Njpvus 

385. — A  Young  Woman  with  Multiple  Na^vi  and  an  Elevated,  Hairy  Verrucous 

Nsevus 

386. — Leiomyoma  of  the  Uterus 

387. — Uterus  with  Subserous  Myoma,  Frontal  Section 

388. — Fibromyoma  of  the  Posterior  Wall  of  the  Rectum 

389. — Malignant  Leiomyoma  of  the  Bladder 

390. — Rhabdomyoma  of  the  Temporal  Region 

391. — Papilloma  of  the  Skin  which  has  Been  Growing  for  Thirty  Years 

392. — Section  of  the  Papilloma  Represented  in  Fig.  391 

393. — Section  from  the  Border  of  a  Fissured  Papilloma  of  the  Skin 

394. — Multiple  Papillomas  of  the  Larynx 

395. — Villous  Polyj>  of  the  Urinary  Bladder 

396.^ — Cutaneous  Horn  of  the  Ear 

397. — Cutaneous  Horn  of  the  Nose 

398. — Cutaneous  Horn  of  the  Lip  as  Seen  from  Without  and  upon  Section    . 

399. — Section  from  the  Summit  of  a  Rectal  Polyp 

400. — Cystic  Adenoma  of  the  Parotid  Gland 

401. — Cystadenoma  of  the  Mammary  Gland 

402. — Malignant  Hypernephroma  of  the  Kidney 

403. — Section  from  a  HyiJerne2:»hroma 

404. — Dermoid  Cyst  at  the  Outer  End  of  the  Supraorbital  Ridge     .... 

405. — ^Traumatie  Epithelial  Cyst  of  the  Palm  of  the  Hand 

406. — ^Traumatic  Epithelial  Cyst  of  the  Index  Finger 

407. — Cholesteatoma  of  the  Skull  Bones,  which  has  Invaded  the  Orbit 

408. — Multilocular  Cystoma  of  the  Mandible  (Adamantinoma)         .... 

409. — Adamantinoma 

410. — Metastatic  Foci  in  the  Axillary  Lymph  Noiles  Secondary  to  a  Carcinoma 

of  the  Breast 

411. — Carcinomatous  Lymph  Nodes 

412. — Scirrhus  of  the  Breast  with  Secondary  Nodules  in  the  Skin    .... 
413. — Metastatic  Foci  in  the  Liver,  Secondary  to  a  Carcinoma  of  the  Rectvun 
414. — Section  from  an  Epithelioma  of  the  Lower  Lij),  Showing  I'pithelial  Pearls 
415. — Superficiial  Carcinoma  of  the  Skin  of  the  Nose 

416. — Superficial  Carcinoma  of  the  Skin 

417. — Superficial  Carcinoma  of  the  Nose  of  Ten  Years'  Standing 
418. — Superficial  Basal  Cell  ('arcinoma  of  the  Skin      .... 
419. — Nodular  ("arcinoma.  Dcvelojjed  upon  a  Varicose  IHcer  of  tlie  Ijcg 
420. — (yaulifiowcrlike  ('arcinoma  of  the  Back  of  the  Hand 
421. — Carcinoma  of  the  Neck,  Secondary  to  a  Carcinoma  of  (he  Lii> 

422. — Carcinoma  of  the  Tongue 

423. — Pa])illoma,  and  (Carcinomatous  Ulcer 

424. — Pai)illary  Carcinoma  of  the  Corona  (ilands  aiul  Prejjuce 

425. — Nodular  Carcinoma  of  the  Maxilla 

426. — Deep  Carcinoma  of  the  Penis,  wi(h  l)es(ruc(ion  of  the  (ilans 

427. — ('arcinoma  of  the  Lower  Lip ,        . 

428. — (Jylindrical-((!ll  Carcinoma  of  the  Rectum  .... 


pa(;k 
879 
880 
882 
883 
884 

885 
887 
888 
889 
890 
392 
899 
899 
900 
900 
901 
901 
901 
902 
906 
908 
909 
910 
911 
914 
918 
918 
920 
922 
923 

932 
933 
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936 
938 
939 
941 
942 
943 
946 
947 
948 
949 
950 
050 
951 
952 
952 
953 


LIST   OF    ILLUSTRATIONS 


XXIX 


FltlURE 

429. — Colloid  Carcinoma  of  the  Rectum         .... 

430. — Nodular  and  Papillomatous  Carcinoma  of  (ho  Reclu 

43  L — Colloid  Carcinoma  of  the  Rectum 

432. — Nodular,  Circular  Carcinoma  of  the  Caecum 

433. — Ulcerated  Superficial  Carcinoma  of  the  Rectum 

434. — Section  Through  Carcinoma  Represented  in  Fig.  4.'5 

435. — Carcinoma  of  the  Breast  (Scirrhus) 

436. — Section  Through  a  ('arcinoma  of  the  Breast 

437. — Lymphangio-endothelioma  of  the  Skin 

438. — Hiemangio-endothelioma  of  the  Kidney 

439. — Perithelioma  of  the  Thyroid  Gland 

440. — Psammoma  of  the  Dura 

441. — Cylindroma  of  the  Orbit 

442. — Mixed  Tumor  of  the  Parotid  Ciland      . 

443. — Benign  Mixed  Tumor  of  the  Soft  Palate 

444. — A  Teratoma 

445. — Hydrops  of  the  Gall-bladder 

446. — Atheroma  of  the  Ear      .... 

447. — Enucleated  Sebaceous  Cysts 

448. — Multiple  Atheromas  of  the  Scalp 

449. — Large  Echinococcus  Cyst  in  the  Muscles  of  the  Back 


PAGE 

954 
954 
955 
956 
956 
957 
958 
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964 
965 
966 
967 
968 
971 
972 
983 
988 
989 
990 
990 
998 


PART   I 
WOUNDS,  THEIR   TREATMENT  AND    REPAIR 


CHAPTER    I 

WOUNDS 

Definition. — A  wound  is  a  solution  of  continuity  of  the  external  cov- 
erings of  the  body,  its  mucous  membranes,  or  the  surfaces  of  organs. 
Wounds  are  chissified  as  simple  if  the  deeper  structures  are  not  injured, 
as  complicated  if  they  are  (viz.,  associated  injury  of  muscles,  nerves, 
large  vessels,  bones,  body  cavities,  and  joints;  cf.  Part  IV). 

Different  Kinds  of  Wounds  and  Causes. — The  form  of  the  wound  de- 
pends upon  the  character  of  the  vulnerating  force,  whether  sharp,  blunt, 
cutting,  crushing,  or  lacerating.  The  principal  forms  of  wounds  are 
the  incised,  contused,  and  lacerated. 

Incised  wounds  produced  by  a  sharp  instrument  or  object  (fragment 
of  glass)  have  well-defined  smooth  edges  and  surfaces,  the  tissues  of 
which  are  not  otherwise  injured.  The  edges  of  the  wound  may,  how- 
ever, be  bluish  in  color,  bruised  and  infiltrated  with  blood,  and  the 
adjacent  area  swollen,  if  the  wound  has  been  made  by  an  imperfectly 
sharpened  instrument  or  dull  object,  or  if  the  blow  has  been  delivered 
with  considerable  force,  or  tangentially,  or  if  a  gash  has  been  made  with 
a  sharp  weapon.  The  extent  to  which  a  woinid  gapes  depends  upon  its 
relation  to  the  tension  planes  of  the  skin.  If  the  wound  crosses  these  at 
right  angles,  for  example,  if  it  is  transverse  on  the  extremities,  longitudinal 
on  the  sides  of  the  thorax  and  abdomen,  its  edges  will  be  widely  sepa- 
rated. The  edges  of  even  a  large  wound  may  be  closely  approximated 
if  its  direction  corresponds  to  the  course  of  the  elastic  fiber  bundles  of 
the  skin.  In  operative  incisions  this  fact  should  always  be  borne  in 
mind,  as  the  resulting  scar  will  be  better  if  the  incision  follows  tension 
planes  (Koeher).     (Fig.  1.) 

In  incised  wounds  and  gashes  in  which  the  skin  is  divided  ob- 
liquely instead  of  vertically,  flaps  are  formed  which  are  connected  with 
the  body  by  pedicles  of  different  widths.  If  the  pedicle  is  entirely  cut 
2  1 


WOUNDS,   THEIR  TREATMENT  AND  REPAIR 


Fig.  1. — Directions  of  the  Tension  Planes  of  the  Skin. 


across  there  is  then  a 
loss  of  substance  or  a 
defect.  Such  wounds 
are  produced  by 
blows  which  are  de- 
livered almost  par- 
allel to  the  surface 
of  the  body. 

Punctured  wounds 
have  the  character- 
istics of  incised 
wounds.  They  are  al- 
ways narrow  and 
deep,  corresponding 
somewhat  in  diame- 
ter to  the  penetrating 
weapon  or  instrument 
(viz.,  needle,  nail, 
dagger,  sword,  lance, 
arrow,  trocar).  They 
gape  little  because 
they  are  so  narrow 
that  their  edges  often 
adhere.  Their  edges 
are  contused  and  lac- 
erated only  when  the 
wound  is  produced  by 
a  blunt  object,  such 
as  a  picket,  a  cane,  or 
an  umbrella. 

The  borders  of 
contused  wounds  are 
irregular,  discolored, 
and  raised  by  the  ex- 
udation of  blood  into 
the  tissues.  Abra- 
sions of  the  skin,  sub- 
cut  a  n  e  ()  u  s  h  te  m  o  r  - 
rluiges,  iscliaviiiia,  and 
loss  of  sensibility  in- 
dicate the  extent  of 
the  cutaneous  area  in- 
volved  in  the  injury 


WOUNDS  3 

produced  by  the  blunt  force.  If  in  addition  the  subcutaneous  tissue  is 
crushed  and  separated  from  the  skin  by  an  oblique  thrust  or  blow,  the 
edges  of  the  wound  may  be  raised  from  the  subjacent  tissues  and  large 
pockets  filled  with  blood  coagulum  formed. 

Contused  wounds  are  more  frequent  where  bones  lie  near  the  surface 
than  where  a  large  amount  of  soft  tissue  intervenes.  The  gaping  of 
contused  wounds  depends  not  only  upon  their  direction,  but  also  upon 
the  amount  of  cutaneous  and  subcutaneous  blood  infiltration.  In  sub- 
cutaneous injuries  of  the  abdomen  contusions  of  the  stomach  and  intes- 
tines and  of  those  viscera  which  may  be  forced  against  the  vertebral 
column  are  relatively  common. 

Lacerated  wounds  are  produced  by  blunt  objects,  the  force  being 
applied  obliquely,  with  a  resulting  tearing  and  rupture  of  the  skin 
or  mucous  membrane.  Their  edges  are  irregularly  torn,  but  the  sur- 
rounding area  is  less  involved  than  in  contused  wounds.  Bursting 
wounds  and  rupture  of  organs  resemble  lacerated  wounds.  Such 
wounds  of  the  skin  are  produced  by  explosions,  as,  for  example,  lacera- 
tions of  the  cheeks  caused  by  the  discharge  of  a  weapon  into  the  mouth 
with  suicidal  intent.  Lacerations  of  vascular  organs  or  those  filled  with 
fluid  contents  (spleen,  liver,  kidney,  heart,  bladder,  stomach,  intestine) 
are  produced  by  the  application  of  blunt  force  to  their  surfaces,  or  by 
projectiles  penetrating  with  great  velocity. 

Many  M^ounds  are  produced  by  the  simultaneous  contusion  and  lacer- 
ation of  tissues,  and  are  then  frequently  accompanied  by  the  formation 
of  flaps  or  the  loss  of  substance.  Machine  injuries,  bites,  scratches,  and 
gunshot  wounds  belong  to  this  class.  In  gunshot  wounds,  the  grooved 
or  grazing  wound  in  which  the  projectile  passes  parallel  to  the  skin  is 
differentiated  from  the  penetrating  Avound,  Avhich  has  a  wound  of  en- 
trance, and,  if  the  projectile  perforates,  a  wound  of  exit.  Contusions 
and  lacerations  are  common  in  large  wounds  of  exit,  in  those  cases  in 
which  the  projectile  strikes  transversely,  and  in  injuries  produced  by 
fragments  of  a  bomb. 

Immediate  Symptoms. — The  innnediate  symptoms  caused  by  a  simple 
wound  are  local  and  consist  of  pain  and  haemorrhage.  General  symp- 
toms (shock,  ana?mia)  more  frequently  accompany  complicated  wounds 
and  those  associated  with  profuse  haemorrhage.  The  pain  at  the 
time  of  the  injury  and  following  it  varies  in  intensity,  depending  upon 
the  susceptibility  of  the  patient,  the  cause  of  the  injury,  and  the  part 
of  the  body  involved.  The  more  rapid  the  separation  of  tissues,  the 
sharper  the  penetrating  object,  the  less  the  pain  is.  Wounds  of  the 
lips,  tongue,  tips  of  the  fingers,  external  genitalia,  and  anal  region  are 
especially  painful.  The  pain  in  the  wound  caused  by  the  exposure  of 
sensory  nerve  fibers  is  perceived  as  a  burning  or  throbbing  sensation. 


4  WOUNDS,  THEIR  TREATMENT  AND  REPAIR 

Pain  disappears  after  the  application  of  a  dressing  or  rest  of  the 
wounded  part ;  most  quickly  in  clean,  rapidly  agglutinating  wounds 
and  sutured  incised  wounds  (operation- wounds).  After  gunshot  wounds 
and  severe  contusions,  the  wound  and  adjacent  area  may  be  completely 
insensitive  for  some  hours  or  days  (local  wound-stupor,  tissue-shock). 
This  condition,  due  to  the  concussion  of  peripheral  nerves,  is  frequently 
accompanied  by  symptoms  of  mild  shock  (paleness,  cold  sweat,  apathy, 
and  unrest)  ;  (cf.  Shock,  Part  IV), 

Haemorrhage, — Haemorrhage  in  a  simple  wound  is  greatest  if  the  sepa- 
ration of  tissue  is  produced  by  a  sharp  instrument.  The  troublesome 
hamiorrhage  following  a  superficial  razor  cut  is  w^ell  known  to  every- 
one. The  greater  the  contusion  and  the  laceration,  the  less  the  haBm- 
crrhage,  for  the  contused  and  lacerated  vessels  do  not  remain  open  so 
long  as  when  cut  transversely.  They  are  closed  by  agglutination  in 
contusions  and  by  the  inversion  of  their  walls  in  lacerations;  also  by 
the  coagulation  of  the  blood  discharged  into  the  tissues.  This  differ- 
ence in  closure  is  found  even  in  large  vessels.  Punctured  and  gunshot 
wounds  with  fine,  narrow  channels  rarely  bleed,  as  they  are  occluded  by 
blood  clots  and  closed  by  muscle  tension. 

Classification. — Haemorrhage  may  be  classified  as  capillary  or  paren- 
chymatous, venous  and  arterial.  In  capillary  haemorrhage  the  blood  oozes 
steadily  from  the  wound  surfaces.  Separate  bleeding  points  which  may 
be  seen  after  sponging  and  become  rapidly  lost  in  the  general  oozing, 
correspond  to  small  vessels.  Arterial  hsemorrhage  is  recognized  by 
the  bright  red  blood,  which  is  discharged  in  spurts  which  increase 
with  the  pulse  beat.  Only  in  dyspnoea  is  dark  blood  discharged 
from  the  arteries.  Venous  haemorrhage  is  recognized  by  the  dark 
blood  which  is  discharged  in  feeble  spurts  from  the  large  veins. 
Venous  haemorrhage  is  greatest  when  there  is  an  obstruction  to 
the  return  venous  flow,  resulting  in  stasis.  The  most  severe  venous 
ha'morrhage,  aside  from  that  due  to  injury  of  large  veins,  follows  in- 
juries of  venous  plexuses  (pampiniform,  pterygoid,  corpora  cavernosa 
penis). 

Primary  haemorrhage,  which  follows  immediately  the  reception  of 
a  wound,  is  differentiated  from  secondary  haemorrhage,  which  may  fol- 
low after  some  days  (six  to  ten)  the  mechanical  separation  or  destruc- 
tion by  suppuration  of  the  thrombus  occluding  the  vessel. 

The  prognosis  of  repair  is  most  favorable  in  incised  wounds,  for 
here  there  are  no  recesses  or  niches  to  harbor  bacteria  and  no  contused 
or  detaclied  particles  to  become  necrotic  and  disturb  healing.  Wounds 
with  contused  and  lacerated  edges  and  surfaces  aft'ord  the  most  un- 
favorable prognosis.  Inflammation  easily  arises,  and  the  separation  of 
necrotic  fragments  leads  to  protracted  healing  with  the  formation  of 


THE  TREATMENT  OF  WOUNDS  5 

granulation  tissue.  The  most  injpoilant  re(|uireuieiit  in  operation- 
wounds  is  that  they  be  clean-cut,  and  that  contusion  and  Ulceration  of 
the  tissues  be  avoided. 


CHAPTER    II 

THE    TREATMENT    OF    WOUNDS 

CONTROL   OF   HAEMORRHAGE 

The  first  indication  in  the  treatment  of  wounds  concerns  the  hremor- 
rhage,  the  control  of  which  may  be  temporary  and  permanent. 

Temporary  Control  of  Hsemorrhage. — The  temporary  control  of  htem- 
orrhage  in  accidents  is  the  duty  of  the  first  aid.  He  who  performs  this, 
whether  layman  or  doctor,  should  know  that  he  does  more  harm  than 
good  if  he  infects  the  wound.  This  consideration  may  be  neglected  only 
in  haemorrhages  from  large  vessels  which  threaten  life.  Compression 
of  the  wound  with  the  bare  hand,  handkerchiefs,  sponges,  and  other 
articles  favors  and  increases  the  dangers  of  infection.  The  popular 
method  of  irrigation  with  haemostatic  agents  (cold  spring  water,  ice 
water,  vinegar,  alum,  salt  solution,  zinc  chloride)  by  which  bacteria  are 
carried  from  the  surrounding  area  into  the  wound  or  from  its  surface 
into  its  deptlis,  and  the  resulting  eschar  formation  favor  the  develop- 
ment of  infection.  For  these  reasons  the  irrigation  and  the  tamponing 
of  wounds  are  to  be  avoided,  and  the  control  of  the  luvmorrhage  by 
direct  compression  to  be  permitted  only  when  sterile  dressings  are  at 
hand.  "Without  Aviping  away  the  dirt  and  coagulated  blood,  gauze  is 
laid  upon  the  wound,  care  being  taken  that  the  part  of  the  gauze  touched 
by  the  fingers  does  not  come  in  contact  with  the  wound  surfaces. 

Control  of  Haemorrhage  by  Pressure. — In  wdunds  of  the  extremities 
a  few  turns  of  a  roller  bandage  applied  over  tlie  gauze  from  the  pe- 
riphery afiford  sufficient  pressure  to  control  the  ha'morrhage  from  small 
arteries.  In  case  of  necessity  freshly  laundennl  cloths  may  be  used  in- 
stead of  sterile  gauze.  If  this  <-'ilistitutt'  is  wanting,  it  is  better  to  h^ave 
the  wound  alone  than  to  cover  it  with  soiled  dressings. 

In  severe  arterial  haemorrhage  digital  compression  must  be  applied 
immediately  to  the  injured  artery  proximal  to  the  Avound.  After  the 
division  of  the  small  arteries  of  the  extremities  (dii:italcs  or  dorsalis 
pedis)  or  subcutaneous  veins,  elevation  to  the  vertical  position  generally 
suffices  to  control  hamiorrhage.  In  tlie  constriction  of  the  extremity  by 
Esmarch's  elastic  bandage,  which  has  found  ])i-actical  application  and 
extensive  use  in  the  constrictor  named  after  him,   we  have  a  method 


WOUNDS,  THEIR  TREATMENT  AND  REPAIR 


never  to  be  neglected  in  controlling  haemorrhage.  Several  turns  of  the 
constrictor  are  applied  to  the  elevated  limb  close  to  the  trunk,  and 
then  it  is  noted  whether  the  haimorrhage  ceases  or  increases,  whether 

the  skin  is  white  or 
cyanotic.  If  the  con- 
strictor produces  a  ve- 
nous stasis  it  should  be 
removed  immediately 
and  reapplied  more 
tightly.  Any  kind  of  a 
rope  or  strap,  cloth,  or 
strip  of  linen  may  be 
used  in  place  of  the 
elastic  constrictor,  and 
if  its  ends  are  tied 
about  a  cane  or  an  um- 
brella, torsion  can  be 
made  until  the  constric- 
tion controls  the  hem- 
orrhage. The  simple 
and  easily  procured 
Esmarch  constrictor  has 
supplanted  the  old  and 
unreliable  tourniquet 
and  similar  devices  by 
which  a  pad  or  other  resistant  object  was  buckled  or  bound  over  the 
trunk  of  the   artery    to   comjiress   it   against   bone. 

Control  of  Haemor- 
rhage from  Mucous 
Membranes. — In  severe 
haemorrhage  from  nui- 
cous  membranes  (nose, 
gums,  tongue)  rinsing 
with  cold  water  or  vine- 
gar, or  preferably  with 
a  five  per  cent  solution 
of  hydrogen  peroxide 
frequently  suffices  in 
ease  there  is  no  consti- 
tutional condition  like 
ha'iiiopliiIi;i. 

The  Use  of  Esmarch's  Elastic  Constrictor. — In   ()[)t"rali()iis  upon  the 
extremities  a  temporary  control  of  haemorrhage  by  artificial  ischaemia, 


Fig.  2. — Digital  Pressure  on  Femoral. 


Fic 


3. — Digital  Compression  of  the  lijiACHiAL 
Against  the  1-?one. 


THE  TREATMENT  OF  WOUNDS 


Fig.  4. — Elastic  Bajndaue. 


introduced  by  Esmarch  in  1873,  is  of  great  advantage,  as  the  blood  is 
excluded  from  the  part  and  an  excellent  view  of  the  bloodless  tissue  can 
be  had. 

Constriction  of  an  extremity,  according  to  Esmarch,  consists  in  the 
application  of  a  thin  India-rubber  bandage  from  the  periphery  to  the 

trunk  to  force  out  the  blood. 
This  procedure  may,  how- 
ever, be  omitted,  for  the  ele- 
vation of  the  extremity  for 
some  minutes  (preferably 
during  the  process  of  steril- 
ization) accomplishes  the 
same  purpose.  The  applica- 
tion of  tliis  bandage  from  the 
periphery  to  the  trunk  may 
be  dangerous  in  inflammation 
and  thrombosis,  as  harmful 
materials  may  be  forced  into 
the  circulation  by  it.  This  seems,  however,  to  be 
more  a  theoretical  danger  than  an  actual  one,  and 
should  not  prevent  the  use  of  the  bandage  M^hen  it  is 
greatly  needed.  India  rubber,  silk  or  cotton  web- 
bing, provided  with  a  clasp  or  hooks  and  eyes,  can 
be  used  for  purposes  of  constriction.  For  the  more 
massive  portions  of  the  limbs  (thigh,  shoulder)  rub- 
ber tubing  of  a  finger's  thickness  provided  with  an 
apparatus  for  fastening  can  be  used.  The  band  or 
tubing  is  applied  under  tension  near  the  trunk, 
several  turns  are  made,  care  being  taken  that  the 
skin  does  not  intervene  between  the  separate  turns 
of  the  constrictor.  Constriction  of  the  forearm  and 
leg  is  best  accomplished  with  the  rubber  webbing 
or  a  thin  pure  rubber  band- 
(]\rartin's  bandage).  A 
rubber  tubing  suffices 
the  fingers,  toes,  penis, 
and  scrotum. 

D  u  r  i  n  g  the 
operation  or  at  its  completion  (viz., 
amputation,  joint  resection,  seques- 
trotomy,  incision  of  phlegmon),  all 
vessels  which  are  visible  in  the  bloodless  tissue  should  be  seized  and 
ligated.     After  procedures  in  which  the  wound  is  not  sutured,  but  tam- 


FiG.  5. — Elastic  Rand- 
age  Appi-ikd. 


Fig.  G. — Martin's  Baxd.^ge. 


8  WOUNDS,  THEIR  TREATMENT  AND  REPAIR 

poned  because  of  inflamination,  the  ligation  of  the  larger  vessels  suffices, 
if  a  well-padded  and  firm  bandage  is  applied  before  the  constrictor  is  re- 
moved, and  the  extremity  then  suspended  or  elevated  for  the  succeeding 
twenty-four  hours.  When  the  circulation  is  reestablished  considerable 
htemorrhage  may  occur  as  the  result  of  a  temporary  paralysis  of  the  ves- 
sel wall  due  to  the  constriction.  For  this  reason  Esmarch's  method  has 
been  condemned  by  some  in  spite  of  the  fact  that  such  haemorrhage  can  be 
easily  controlled.  If  even  pressure  with  a  large  gauze  compress  is  made 
while  the  constrictor  is  being  removed,  and  is  continued  for  some  minutes 
while  the  extremity  is  elevated,  the  capillary  haemorrhage  (following 
removal  of  the  constrictor)  can  be  controlled.  If  the  compress  is  re- 
moved the  small  spurting  vessels  and  bleeding  points  can  be  seized  and 
ligated.    When  the  wound  is  dry  it  can  be  sutured. 

If  the  constriction  is  applied  longer  than  two  and  a  half  or  three 
hours,  or  the  rubber  tubing  applied  to  weak  extremities  with  consider- 
able force,  nerve  injuries,  ischa^mic  muscle  paralysis,  and  necrosis  of 
the  skin  may  follow.  These  results  are  seen  most  often  in  patients  who 
have  been  transported  some  distance  after  their  injury  or  after  opera- 
tion, when  the  constrictor  has  not  been  removed.  Esmarch's  ischaemia 
is  to  be  avoided  unless  very  necessary  in  lymphangitis,  thrombosis,  and 
thrombo-phlebitis,  because  of  the  danger  of  separation  of  the  thrombus. 

The  permanent  control  of  haemorrhage  is  obtained  by  the  use  of 
aseptic  tampons,  compresses,  and  ligatures.  Other  methods,  such  as 
eschar  formation  by  actual  cautery  and  haemostatic  agents,  and  angio- 
tripsy,  are  to  be  recommended  for  certain  cases  only. 

Control  of  Capillary  Haemorrhage  and  Haemorrhage  from  Venous 
Plexuses. — In  accidental  wounds,  one  may  proceed  to  the  control  of  the 
haemorrhage  after  sterilization  of  the  adjacent  area.  If  necessary  the 
Esmarch  constrictor  may  be  applied  and  the  wound  covered  temporarily 
with  sterile  gauze  while  the  field  of  injury  is  being  sterilized.  After  the 
removal  of  the  constrictor  the  bleeding  points  are  ligated  as  in  opera- 
tion-wounds. Capillary  haemorrhage  and  hivmorrhage  from  venous 
plexuses  (not  controlled  by  ligature)  are  easily  controlled  by  a  tampon 
of  iodoform  gauze,  which  also  stops  luvmorrliage  by  the  gradual  absorp- 
tion of  fluids  by  the  gauze  and  resulting  swelling,  without  injuring  the 
tissues  or  delaying  repair.  This  gauze  is  therefore  the  most  important 
agent  in  controlling  haemorrhage  from  cavities,  from  the  nuicous  mem- 
branes of  the  nose,  vagina,  and  rectum,  and  in  parenchymatous  haemor- 
rhage following  the  rupture  of  vascular  organs  (liver,  spleen,  and  kid- 
ney). The  actual  cautery  has  likewise  a  h;emostatic  action  in  these  cases, 
but  is  not  e(|nal  to  the  gauze,  because  it  is  more  a])t  to  interfere  with 
wound  repair.  Transfixion  suture  is  frequently  of  great  value  in  con- 
trolling ha-morrliage  from  vascular  organs,  kidney,  etc. 


THE  TREATMENT   OF   WOUNDS 


9 


The  Actual  Cautery  as  a  Hsemostatic  Agent. — The  actual  cautery,  in 
the  form  of  a  platiinuu  point  maintained  at  red  heat  by  benzine  vapor, 
has  replaced  the  hot  iron  (ferrum  candens)  which  was  used  in  olden 
times  to  control  ha-morrhage  during  operations  (amput-ation  with  red- 
hot  knife).  The  cautery  is  valuable  in  controlling  luemorrhage  from 
mucous  membranes,  where  the  tampon  cannot  be  applied — viz.,  from 
buccal  cavity,  hamiorrhoids,  and  from  superlieial  vascular  tumors 
(hamaugiomas.  sarcomas,  carcinomas).  Where  a  superficial  action  only 
is  necessary,  the  cautery  may  be  replaced  by  Ilollaeuder 's  hot-air  appa- 


FiG.  7. — Paquelix's  Thermo-Cautery. 


ratus,  by  which  hot  air  is  blown  upon  the  bleeding  surfaces.  Cauteri- 
zation of  bleeding  wounds  is  to  be  avoided  unless  indicated,  as  the  eschar 
retards  healing  and  favors  inflammation.  The  cautery  is  being  em- 
ployed less  and  less  each  year  as  a  ha'mostatic  agent. 

The  same  may  be  said  of  other  ha?mostatic  agents,  such  as  compresses 
saturated  with  liquor  ferrisesquichlorati,  Avhich  forms  with  the  coagu- 
lated blood  and  cauterized  wound  surfaces  a  firm  eschar  which  prevents 
the  discharge  of  wound  secretion. 

Control  of  Haemorrhage  in  Operation-Wounds. — Tn  operation-wounds 
any  haemorrhage  which  is  not  capillary  or  parencbyiiiatous  is  inunedi- 
ately  controlled  by  artery  forceps  and  by  ligation.  This  may  be  effected 
in  different  ways. 


10 


WOUNDS,  THEIR  TREATMENT  AND  REPAIR 


Fig.  8. — Forceps,  Serre-fine 


Artery  clamps  (Frick,  von  Langenbeck,  von  Bergmann)  or  artery 
forceps  (Koeberle,  Pean,  Kocher,  etc.)  are  used  for  this  purpose.  They 
are  differently  construct- 
ed. The  extremity  which 
grasps  the  tissue  is  ribbed 
or  provided  with  inter- 
locking teeth.  The  scis- 
sorlike  handle  is  provided 
with  a  ratchet  lock  or 
clasp. 

As  soon   as   a  vessel  is 
cut  it  is  seized  with  an  ar- 
tery forcep.    The  instrument  is  applied  vertically  to  the  wound  surfaces, 
not  parallel  or  obliquel3^    In  this  way  as  little  of  the  surrounding  tissue 

as   possible   is   grasped.      If 
;^'^'  the    number    of    clamps    or 

forceps  interferes  with  the 
progress  of  the  operation, 
the  vessels  can  be  firmly 
ligated  with  catgut  and  the 
instruments  removed.  In 
case  of  small  vessels  the  sim- 
ple is  better  than  the  surgi- 
cal knot;  the  granny  knot 
should  not  be  used,  for  it 
slips  easily.  It  n]akes  little 
difference  what  technic  is 
employed  in  tying  the  liga- 
ture. The  jfingers  should 
not,  however,  come  in  con- 
tact with  the  wound. 

In  deep  parts  of  the 
wound  artery  forceps  may 
be  used  to  tighten  the  liga- 
tures. Silk  may  be  used  in 
place  of  catgut  in  wounds 
which  are  not  to  be  closed 
by  sutures.  Catgut  is  gen- 
erally to  be  preferred. 

Large   vessels   should   be 

drawn    out    from    the    sur- 

r'oiiii(liiig  1  issues  willi  llic  artery  forceps  and  isolated  by  blunt  dissection. 

A  second  ai'tery  forcep  sliouid  Uien  he  applied  li-ansverscly,  and  the  first 


Fic.  9. — LuiATioN  HY  Transfixion. 


THE  TREATMENT   OF  WOUNDS 


11 


forcop   removed.     The  liuature  then  applied   to  the  vessel   eaii  be   de- 
pended npon,   for  only   the  vessel   and   not  the  surroundiii"^'   tissue   is 
ligated.     Wherever  it  is  necessary  to  jirasp  much  tissue  the  artery  for- 
ceps are  not  adequate,  for  in  the  resistant  tissue  of 
the  scalp  and  friable  muscle,  ligatures  do  not  hold 
1  Wf^jj^^"       -*»    well.     Tliey  frequently  slip  and  interfere  with  the 
-    •''•'  »^  progress  of  the  operation  or  give  rise  to  secondary 

hannon'hage.  In  these  cases  transfixion  is  valual)le; 
a  needle,  carrying  a  catgut  ligature,  is  passed 
through  the  tissue  close  to  the  point  of  the  forccp, 
and  tied  singly  on  one  side,  doubly  on  the  otlier. 

All  visible  vessels  in  loose  tissue  (subcutaneous, 
intermuscular,  omentum,  mesentery,  dura)  should 
be  seized  with  two  artery  forceps  before  division.  The  division  is  then 
made  between  the  forceps.  In  this  way  an  operation  may  l)e  performed 
with  but  little  loss  of  blood.  Larger  vessels  are  best  ligated  in  con- 
tinuity, as  practiced  in  courses  in  operative  surgery.  The  vessel  is  sei)a- 
rated  a  short  distance  by  blunt  dissection  from  its  sheath  and  l)ed,  and 
two  ligatures  are  passed  around  the  artery  by  an  aneui-ysni  needle.  The 
ligatures  are  then  tied  and  the  artery  cut  between  them. 

In  the  so-called  mass  ligature  the  artery  is  not  directly  exi)osed,  but 
the  ligature  is  carried  by 


Fig.  10.  —  Tying  Liga- 
TiKi-;  AFTER  Trans- 
fixion. 


a  needle  or  ligature  car- 
rier directly  through  the 
tissue  (viz.,  omentum, 
mesentery,  peritoneal  ad- 
hesions) and  the  struc- 
tures are  ligated  in  mass. 
Control  of  Hsemor- 
rhage  by  Torsion  of  Ves- 
sels, Angiotripsy,  etc. — 
Control  of  haemorrhage 
by  torsion,  by  twisting 
of  the  applied  artery  for- 
ceps, is  too  unsafe  to  sup- 
plant ligation.  It  may  be 
used  to  the  best  advan- 
tage where  small  arteries 
have  been  seized.  Like- 
wise angiotripsy,  by  which 

is  understood  a  crushing  of  a  vessel  with  powerful  forceps,  is  uiu-eliable. 
This  procedure  was  formerly  practiced  as  forced  compression  (forci- 
pressure).    Haemorrhage  does  not  occur  after  removal  of  the  forceps,  but 


Fig.    11.— Passing    of    Ligatttrk    nKXKATii    AnrrnY 
wiTH  Aneurysm  Nkedi.k. 


12 


WOUNDS,  THEIR  TREATMENT  AND   REPAIR 


sponging  of  the  wound  or  muscular  action  freciuently  provokes  it.  In 
deep,  inaccessible  wounds  (e.  g.,  vaginal  operations)  long,  crushing  for- 
ceps are  used.  In  order  to  guard  against  intermediate  hgemorr-hage  from 
the  uterine  arteries  they  are  allowed  to  remain  from  twenty-four  to  foi'ty- 
eight  hours.  The  control  of  haemorrhage  by  compression  of  the  wound 
wdth  sterile  gauze  is  made  use  of  as  much  as  possible  in  every  operation. 
In  large  wounds  the  gauze  may  be  pressed  against  the  wound  surfaces  by 

the  hand,  in  small  wounds  by  the 
finger.  In  skin  grafting  it  is  neces- 
sary to  compress  the  wound  so  that 
the  healing  of  the  grafts  will  not  be 
interfered  with  by  subsequent  ooz- 
ing. Complete  dryness  of  the  wound 
after  ligation  of  all  spurting  vessels 
and  bleeding  points  is  secured  by 
an  even  compression  of  its  surfaces, 
for  about  ten  minutes,  with  com- 
presses saturated  with  physiological 
salt  or  a  solution  of  three  to  five 
per  cent  hydrogen  peroxide.  The 
tissues  are  not  injured  by  these  appli- 
cations. 

The  Iodoform  Gauze  Tampon. — 
The  iodoform  gauze  tampon  is  indi- 
cated after  operations  in  which  there 
are  bleeding  cavities  with  resistant 
walls  (secpiestrotomies,  resection  of  the  maxilla)  or  wounds  with 
deep  sinuses,  in  which  a  collection  of  blood  is  to  be  avoided;  also  after 
incision  of  acutely  inflamed  tissue,  for  its  capillarity  not  only  controls 
haemorrhage,  but  also  prevents  post-operative  absorption  (vide  Treat- 
ment of-  Pyogenic  Infections,  Part  II). 

Haemophilia. — The  control  of  htemorrhage  is  most  dilficult  even  in 
the  siiKill  superficial  wounds  in  patients  with  diseases  of  the  blood  or 
hemophilia.  By  flu;  latter  is  understood  an  abnormal  condition  char- 
acterized l)y  a  marked  pr(Mlispositi<m  to  spontaneous  and  traumatic  ha'in- 
ori'hages.  The  essential  cause  is  not  known.  Lessened  coagulability  of 
llic  1)1(1(1(1,  abnoiMiial  thinness  of  the  vessel  walls  which  are  not  other- 
wise changed,  and  a  dilatation  of  the  vessels  through  vaso-motor  in- 
fluences have  all  been  suggested. 

The  disease  is  most  frequently  congenital,  and  the  male  sex  is  prin- 
cipally afflicted;  thiileen  times  more  fre(iueiitly  than  the  female.  Trans- 
ference from  the  diseased  father,  or  from  the  grandfather  through  a 
healthy  mollicr,  ciui  (iccur. 


Fig.  12.— Torsion  of  an  Artery. 


THE  TREATMENT  OF  WOUNDS  13 

Spontaneous  hfemorrhages  occur  especially  from  the  mucous  mem- 
branes of  the  nose,  mouth,  intestine,  and  bladder,  and  into  the  joints, 
producing  often  severe  changes  in  the  latter  (vide  Hainiarthrosis).  Be- 
sides, ha?morrhages  may  occur  in  the  bursae,  the  subcutaneous  tissue,  and 
kidneys. 

The  slightest  injury  of  the  skin  or  mucous  membrane,  such  as  a 
needle  prick,  incised  or  lacerated  wound  of  the  fingers,  laceration  of  the 
gums  in  cleaning  or  extracting  teeth,  may  be  followed  by  severe  ha-mor- 
rhage,  which  may  continue  with  slight  interruption  for  days  and  weeks, 
and  even  terminate  fatally. 

The  Control  of  Haemorrhage  in  Haemophilia. — Often  a  firm  iodoform 
tampon  applied  after  preliminary  cauterization  of  the  wound  with  the 
actual  cautery  will  control  the  htemorrhage.  The  pressure  by  bandages 
and  elevation  of  the  extremity  should  of  course  be  combined  with  this 
treatment.  Among  the  many  methods  which  have  been  suggested,  gelatin 
has  of  late  received  the  most  thorough  trial.  According  to  Dastre  and 
Floresco  gelatin  increases  the  coagulability  of  the  blood.  It  may  be  used 
locally  in  the  form  of  a  five  or  ten  per  cent  solution  heated  to  10-4°  or 
140°  F.,  which  is  applied  to  the  wound  by  saturated  gauze  compresses,  or 
injected  into  joints.  For  systemic  effects  it  is  injected  subcutaneously 
into  the  skin  of  the  thorax  or  abdomen.  One  to  two  hundred  c.c.  of  a  one 
to  two  per  cent  solution  heated  to  99°  F.  are  injected  daily  luitil  the 
ha?morrhage  ceases. 

The  solution  consists  of  gelatin  and  physiological  (0.9  per  cent)  salt 
solution.  It  is  sterilized  by  heating  twice  to  248°  F.,  with  an  interval 
of  one  or  two  days  between  sterilizations.  It  is  warmed  over  a  water 
bath  each  time  before  using.  The  use  of  gelatin  is  at  present  a  very 
limited  one. 

Spontaneous  Cessation  of  Haemorrhage. — The  organism  is  not  defense- 
less against  loss  of  blood.  It  is  possessed  of  a  numlx-r  of  means  of 
checking  and  stopping  it,  w^hich  are  only  successful,  however,  when  the 
blood  is  discharged  slowly,  and  not  in  severe  haemorrhage  resulting  from 
the  transverse  division  of  large  arteries. 

It  is  well  known  that  a  simple  wound,  even  an  incised  wound,  ceases 
to  bleed  after  some  time.  This  is  true  in  operation-wounds,  and  there- 
fore it  is  a  rule  in  all  operations  to  grasp  bleeding  points  immediately, 
not  only  to  limit  the  amount  of  blood  lost,  but  also  to  guard  against  sec- 
ondary haemorrhage  from  the  small  vessels,  which  cease  bleeding  spon- 
taneously during  the  operation  and  Avould  therefore  be  overlooked. 

The  change  in  the  size  of  th(^  lumen  of  the  vessel  is  the  fii-sf  factor 
in  the  spontaneous  cessation  of  ha'morrhage.  The  lumen  is  nan-owed  by 
the  contraction  of  the  circular  fil)ers  of  the  vessel  walls;  the  cai)illaries 
are  narrowed  by  the  swelling  of  their  endothelium.    Vessels,  because  of 


14  WOUNDS,  THEIR  TREATMENT  AND  REPAIR 

their  elasticity,  retract  from  the  wound  surfaces,  and  the  bh)od  is  then 
forced  into  the  protruding  tissues  and  the  vessel  sheath.  The  blood  co- 
agulates rapidly  and  closes  the  lumen  and  the  lateral  wounds  of  the 
vessels  (vide  Injuries  of  Arteries  and  Veins,  Traumatic  Aneurysms,  etc.). 

The  spontaneous  cessation  of  heemorrhage  after  the  ti-ansverse  divi- 
sion of  large  vessels  depends  upon  the  lowering  of  blood  pressure  and 
changes  in  cardiac  action.  A  slight  loss  of  blood  produces  at  first  a  tran- 
sitory lowering  of  blood  pressure,  which  is  again  rapidly  restored  by  a 
contraction  of  the  vessel  walls  resulting  from  an  irritation  of  the  vaso- 
motor centers  produced  by  the  ana?mia.  If  a  large  amount  of  blood  is 
lost,  which  in  animal  experiments  amounts  to  more  than  one  fourth  of 
the  total  quantity,  the  blood  pressure  sinks  rapidly  and  the  heart  beat 
becomes  more  feeble. 

If  the  haemorrhage'  ceases,  the  lumen  of  the  vessel  is  closed  by  a 
thrombus  since  the  coagulability  of  the  blood  is  increased.  The  lymph, 
either  because  the  tension  of  the  tissues  exceeds  the  blood  pressure  or 
because  of  the  dilatation  of  the  capillaries  by  vaso-motor  influences 
(Grawitz),  flows  into  the  blood,  carrying  with  it  numerous  leucocytes, 
and  restores  the  lost  fluids. 

According  to  Goltz,  death  from  haemorrhage  results  from  the  empty 
condition  of  the  heart.  The  blood  pressure  becomes  so  low  and  the 
amount  of  blood  is  so  reduced  that  no  blood  is  received  from  the  venous 
system,  and  after  systole  the  heart  does  not  dilate  again. 

Dangers  of  Haemorrhage  Relative  to  Age,  etc. — The  dangers  of  haem- 
orrhage are  greatest  in  children.  The  loss  of  a  few  c.c.  in  the  new  born 
and  of  250  c.c.  in  a  child  one  year  old  is  dangerous.  In  the  adult  a 
similar  danger  arises  as  a  rule  only  after  the  loss  of  one  half  the  total 
amount.  Women  recover  from  heemorrhage  more  rapidly  than  men. 
It  is  difficult  to  determine  how  much  of  the  total  quantity  of  blood 
(amounting,  as  a  rule,  to  one  thirteenth  of  the  body  weight)  may  be  lost 
without  proving  fatal,  as  a  number  of  factors  have  to  be  considered. 

In  the  first  place  the  rapidity  of  loss  is  a  factor,  as  the  danger  in- 
creases with  it.  Diseases  of  the  heart  and  arteries  (arterio-sclerosis), 
anannia  of  the  brain  as  in  shock,  severe  anaemias  following  exhausting 
diseases,  the  effects  of  long  operations,  and  narcosis  increase  the  dangers 
of  hajmorrhage. 

AFTER-TREATMENT  OF  HEMORRHAGE 

Restoration  of  the  Blood. — The  blood  is  restored  by  absorption  of 
fluids  from  the  tissues;  this  accounts  for  the  feeling  of  thirst  expe- 
rienced in  hajiiiorrhage.  After  a  short  time  the  leucocytes  (post-haemor- 
rhagic  leucocytosis)    increase,   after  a   longer  time  the  red  blood  cor- 


THE  TREATMENT  OF  WOUNDS  15 

puscles.  The  time  required  for  complete  restoration  of  the  bh)od 
depends  upon  the  age,  the  nutrition,  and  the  condition  of  tlie  patient. 
This  restoration  is  to  be  expected  in  from  two  to  five  days  after  slight 
htemorrhages ;  in  from  fourteen  to  thirty  after  severe. 

Venesection. — Bleeding  (venesection),  a  method  current  among  pliysi- 
cians  of  an  early  period,  liuds  no  place  in  surgical  practice,  which  always 
endeavors  to  prevent  hgemorrhage.  In  passive  congestion,  resulting  fi-om 
diseases  of  the  heart  or  lungs,  in  chlorosis,  uraemia,  and  eclampsia,  bleed- 
ing thins  the  blood  temporarily  and  thus  improves  the  circulation.  The 
composition  of  the  blood  is  improved  by  a  regeneration  of  blood  cells. 
The  urinary  secretion  is  also  increased.  Bleeding  belongs  therefore  to 
the  therapeutic  measures  of  internal  medicine. 

Teclniic  of  Bleeding. — Bleeding  is  performed  in  the  following  way :  A 
constrictor  is  applied  to  the  arm  to  produce  a  venous  stasis;  the  radial 
pulse  should  not  be  obliterated.  After  the  field  of  opei-ation  is  properly 
prepared,  the  skin  covering  the  distended  median  basilic  vein  is  incised. 
The  vein  is  exposed  at  the  bend  of  the  elbow  and  opened  for  the  distance 
of  about  1  cm.  The  blood  is  caught  in  a  receptacle  and  measured ;  not 
more  than  one  per  cent  of  the  body  weight  (500-1,000  g.)  should  Ix' 
taken.    An  aseptic  dressing  is  then  applied  when  the  bleeding  is  finished. 

The  old  method  of  puncturing  with  the  lancet  should  be  discarded, 
as  injuries  of  nerves  and  arteries  may  be  produced,  and  neuralgia  niul 
arterio-venous  aneurysms  result.  In  every  field  of  surgery  incisions 
should  be  made  layer  by  layer.  Rather  make  an  incision  too  large  and 
suture  it  than  produce  unnecessary  injuries. 

After  some  experience  the  veins  can  be  punctured  through  the  skin 
with  a  syringe,  as  in  taking  of  blood  for  bacteriological  investigation 
{lyide  Blood  Examination  in  General  Pyogenic  Infections),  and  the  de- 
sired amount  of  blood  removed. 

Symptoms  of  Haemorrhage  and  their  Treatment. — The  piiucipal  symp- 
toms of  anaemia  resulting  from  haemorrhage  are  pallor,  pinched  features, 
spots  before  the  eyes,  ringing  in  the  ears,  weariness,  weakness,  thirst, 
rapid,  scarcely  perceptible  pulse,  restlessness,  anxiety,  vomiting,  and 
faintness.  Dyspnoea,  dilated  pupils,  loss  of  consciousness,  cold  sweat, 
convulsions,  involuntary  discharge  of  urine  and  fa'ces  indicate  the 
gravest  danger.  Action  must  be  immediate  if  this  condition  is  to  b(^  suc- 
cessfully treated.  At  the  same  time  that  attempts  to  control  flu'  lueiiior- 
rhage  are  made,  agents  which  strengthen  the  heart,  raise  blood  pres- 
sure, and  increase  the  amount  of  blood  must  be  used. 

The  horizontal  or,  better,  partially  inverted  position  of  the  patient, 
elevation  of  the  arms  and  legs  and  envelopment  of  the  same  in  an  elastic 
bandage  applied  with  little  tension  (autotransfusion),  wrapping  with 
warm  blankets,  subcutaneous  injection  of  severel  hypodermic  syringe- 


16  WOUNDS,  THEIR  TREATMENT  AND  REPAIR 

fills  of  camphorated  oil,  clysters  of  warm  red  wine  mixed  with  cloves 
combat  this  condition.  In  patients  who  are  conscious  and  do  not  vomit, 
hot  coffee,  champagne,  mulled  wine,  hot  extract  of  beef,  and  other  rap- 
idly acting  agents  may  be  given,  but,  most  important,  normal  salt  solu- 
tion slowly  and  continuously  per  rectum.  If  these  do  not  avail,  and 
threatening  symptoms  are  present,  salt  solution  should  be  given  sub- 
cutaneously  to  supply  the  body  with  fluids. 

Transfusion  of  Physiological  Salt  Solution. — The  transfusion  of  physi- 
ological salt  solution  has  supplanted  the  transfusion  of  blood.  The  lat- 
ter is  little  used  to-day,  but  was  practiced  in  the  seventeenth  century, 
particularly  by  Dieffenbach  and  IMartin.  In  this  method  from  140- 
200  c.c.  of  blood  were  removed  from  a  healthy  man  by  bleeding;  the 
blood  was  then  thoroughly  defibrinated,  filtered  through  a  cloth,  warmed 
over  a  water  bath,  and  injected  into  one  of  the  arm  veins  of  the  patient. 
In  spite  of  complete  asepsis,  chills  and  fever  (so-called  transfusion  fever, 
the  equivalent  of  aseptic  fever  accompanying  the  absorption  of  blood 
exudates)  and  severe  general  symptoms  (dyspnoea,  cyanosis,  hiemoglo- 
binuria,  bloody  diarrhoea,  disturbances  of  consciousness)  often  followed. 

Alterations  in  the  composition  of  the  blood  and  extensive  capillary 
thrombosis  caused  these  symptoms.  Embolism  of  the  vessels  of  the  heart 
and  lungs  frequently  produced  death. 

The  fatal  accidents  caused  by  the  transfusion  of  blood  can  be  ex- 
plained in  two  ways.  Firstly,  aside  from  the  entrance  of  air  into  the 
veins  during  the  injection,  small  clots,  in  spite  of  the  filtration  of  the 
defibrinated  blood,  could  be  injected.  Ilueter  attempted  to  overcome 
this  by  injecting  the  defibrinated  blood  into  the  radial  artery,  with  the 
idea  that  the  small  clots  would  be  retained  in  the  capillaries.  Secondly, 
defibrinated  blood  contains  enough  fibrin  ferment  to  make  it  dangerous 
because  of  the  possibility  of  the  formation  of  fibrin. 

The  direct  transfusion  ^  of  blood  from  the  radial  artery  of  the  giver 
into  the  arm  vein  of  the  receiver  has  been  tried  to  overcome  the  disad- 
vantages of  fibrin  ferment  intoxication,  a  procedure  which,  however, 
carries  with  it  the  dangers  of  embolism,  for  clots  readily  form  about 
the  tube  connecting  the  vessels. 

Sheep's  blood,  employed  in  earlier  times,  is  even  more  dangerous 
than  human  blood.  Its  cells  and  those  of  the  blood  of  any  other  species 
are  immediately  destroyed  and  pi-oduce  extensive  coagulation. 

The  dangers  of  blood  transfusion  and  the  recognition  of  the  fact 
that  the  principal  cause  of  death  from  hiemorT'hage  is  the  decrease  in 
blood  pressure  rather  than  the  alteration  of  the  component  parts  of  the 
blood  have  led  to  the  use  of  physiological  salt  solution  as  suggested  by 

'  See  Appendix. 


THE  TREATMENT  OF   WOUNDS  17 

Kroiieeker  and  Sander.  The  advantages  of  the  salt  sohition  are  that  its 
administration  is  simple,  its  action  immediate,  its  safety  al)sohit('  if 
rightly  used. 

Preparation  of  Physiological  Salt  Solution  and  Technic  of  Adminis- 
tration.— Salt  sohition  may  be  given  intra venousl}-  or  subcutancuusly. 
Where  rapid  action  is  necessary  and  the  solution  is  ready,  it  is  given  in- 
travenously. The  0.9  per  cent  solution  can  be  prepared  in  any  hospital 
with  the  boiling  water  of  the  steam  sterilizer,  water  being  received  in 
sterile  pitchers  and  held  in  readiness.  In  practice  outside  of  a  hospital,  it 
may  be  necessary  to  filter  the  tap  water  through  gauze  and  to  boil  it  one 
half  hour  in  case  a  sterile  solution  cannot  be  obtained  from  the  apothe- 
cary. The  solution  is  warmed  to  104°  F.  and  poured  into  a  sterile  irri- 
gator, to  the  tubing  of  which  is  attached  a  hollow  needle. 

After  a  slight  stasis  is  produced  in  the  arm  by  the  pressure  of  the 
hand  or  a  bandage,  the  canula,  the  air  bubbles  having  been  previously 
forced  out  of  it,  is  introduced  into  the  most  prominent  vein  (most  fre- 
quently the  median  basilic).  If  it  is  feared  that  the  vein  will  not  be 
found,  it  may  be  exposed  by  a  small  incision  and  punctured  or  opened  if 
a  blunt  canula  is  used.  In  the  latter  case  the  vein  should  be  ligated  dis- 
talward,  and  a  second  ligature  passed  about  it  proximal  to  the  opening. 
The  solution  should  be  allowed  to  run  into  the  vein  slowly  until  one  or 
two  liters  have  been  given.  After  the  transfusion  is  completed  and  the 
proximal  end  of  the  vein  is  tied  and  the  wound  sutured,  an  aseptic  dress- 
ing should  be  applied.  In  severe  cases  transfusion  may  be  repeated  two 
or  three  times  in  twenty-four  hours,  and  two  liters  given  each  time. 

The  subcutaneous  injections  are  given  with  large  syringes  into  dif-' 
ferent  parts  of  the  body,  most  frequently  the  external  surfaces  of  the 
thighs,  the  abdomen,  and  under  the  breasts.  Too  great  distension  of  the 
skin  and  too  much  pressure  are  to  be  avoided,  because  of  the  severe  pain 
and  the  danger  of  necrosis.  From  one  to  two  liters  should  be  injected,  as 
in  the  intravenous  procedure,  and  if  necessary  the  injections  may  be 
repeated  many  times. 

A  very  simple  and  safe  method  of  using  the  salt  solution  is  to  inject 
it  into  the  rectum,  where  it  is  usually  readily  absorbed,  and  this  is  the 
method  to  be  adopted  except  in  the  severe  cases  where  immediate  action 
is  imperative. 

The  success  of  the  transfusion  is  seen  immediately  in  the  improve- 
ment of  the  circulation,  and  the  organism  gains  time,  except  in  the 
severest  cases,  to  recover  and  to  gradually  restore  the  quality  of  the 
blood.  In  the  severest  eases  salt  solution  cannot  replace  the  constituent 
parts  of  the  blood,  and  the  administration  of  fluids  cannot  prevent  a 
fatal  issue.  In  spite  of  this,  transfusion  of  salt  solution  has  in  many 
cases  a  life-saving  action. 
3 


18  WOUNDS,  THEIR  TREATMENT  AND  REPAIR 

Indication  for  the  Use  of  Physiological  Salt  Solution. — Its  use  is  indi- 
cated ill  all  lueniorrhages  with  tlireateniiig  syiiiptoms  without  exception, 
and  is  often  necessary  during  major  operations  or  at  their  completion. 
Accidents  resulting  from  cardiac  paralysis  and  the  cardiac  weakness 
accompanying  shock  may  be  successfully  combated  in  this  way. 

The  increase  of  tissue  fluids  following  injections  of  salt  solution  im- 
proves the  general  condition  when  there  is  deficient  absorption  of  food 
(e.  g.,  carcinoma  cardia*,  vomiting  after  chloroform,  peritonitis).  It  is 
used  to  advantage  before  operations  on  poorly  nourished  patients. 

The  increased  diuresis  following  the  transfusion  of  salt  solution  has 
led  to  its  use  in  intoxications  (e,  g.,  iodoform,  carbonic-acid  gas,  illu- 
minating gas,  also  uraemia)  and  in  general  infections. 

Combined  Use  of  Physiological  Salt  Solution  and  Oxygen. — In  order 
to  better  the  results  of  the  transfusion  of  salt  solution  in  severe  haemor- 
rhages, Kuettner  has  suggested  to  increase  the  reduced  oxygen  content 
of  the  blood  by  the  simultaneous  administration  of  oxygen  gas,  A  reser- 
voir is  filled  with  1,000  c.c.  of  salt  solution,  and  oxygen  gas  is  allowed 
to  flow  in  from  a  tank  until  100  c.c.  of  the  solution  is  displaced.  The 
reservoir  is  then  closed  and  shaken  until  the  oxygen  is  absorbed  by  the 
solution.  Twenty  c.c.  of  oxygen  can  be  introduced  with  one  liter  of  the 
solution. 

The  salt-soda  solution  (7.5  per  cent  salt  plus  2.5  per  cent  calcined 
sodium)  recommended  by  Tavel  and  used  subcutaneously  has  caused 
extensive  necrosis  of  the  skin. 

MECHANICAL,   CHEMICAL  AND   THERMAL  INJURIES 

Prevention  of  Infection  in  Mechanical,  Chemical,  and  Thermic  In- 
juries.— In  the  care  and  treatment  of  a  wound  there  are  other  important 
considerations  besides  the  control  of  haemorrhage :  The  'prevention  of  the 
entrance  of  injurious  agents,  and  the  restoration  of  conditions  favorable 
to  wound  repair.  Wounds  should  be  protected  from  bacteria,  from  me- 
chanical, chemical,  and  thermal  injuries. 

Operation-wounds  should  be  protected  from  infection  by  the  rigid 
observance  of  an  aseptic  technic.  Every  accidental  wound  should  be 
regarded  as  infected,  for  at  the  time  of  the  injury,  more  frequently,  how- 
ever, during  the  period  immediately  following,  bacteria,  most  often 
pyogenic  and  putrefactive  varieties,  are  introduced  into  the  wound. 
These  primary  wound  infections  only  become  severe,  however,  if  the 
wound  is  improperly  handled;  for  example,  if  an  accidental  wound,  in 
a  condition  unfavorable  for  healing  (because  of  contusion  and  exuda- 
tion of  blood),  is  treated  as  an  aseptic  operation-wound  and  closed  by 
sutures.     As  a  rule  the  secondary  infections  are  much  more  grave.     He 


THE  TREATMENT  OF  WOUNDS  19 

who  touches  the  wound  with  his  fingers,  dresses  it  with  soiled  gauze, 
examines  its  recesses  and  tract  with  a  probe,  other  instrument,  or  finger, 
washes  simultaneously  the  bleeding  wound  and  its  unclean  adjacent  area, 
introduces  an  infection  which  is  of  much  more  significance  than  the 
wound  itself.  It  is  as  much  the  duty  of  the  first  aid  to  prevent  these 
secondary  infections  as  it  is  of  those  who  have  charge  of  the  after-treat- 
ment. In  the  treatment  of  the  wound  the  primary  infections  should 
not  be  permitted  to  develop. 

In  order  to  prevent  infection  during  the  performance  of  the  first 
aid  a  small  packet  has  been  devised  for  use  in  military  practice  which 
consists  of  a  sterile  compress  and  an  attached  bandage.  The  arrange- 
ment (Perthes,  Korteweg)  is  so  simple  and  ingenious  that  when  opened 
the  gauze  comes  directly  in  contact  with  the  wound.  These  packets,  as 
introduced,  for  example,  by  Utermoehlen  for  emergency  dressings  into 
the  Dutch  army,  are  of  great  practical  significance,  for  any  wound  can 
be  immediately  covered  with  sterile  gauze  without  the  danger  of  infec- 
tion with  unclean  hands. 

AVhile  the  clothes  of  the  patient  are  being  removed,  the  emergency 
dressing  should  be  allowed  to  remain,  or  the  wound  should  be  protected 
by  sterile  gauze,  held  in  position  by  a  bandage  or  adhesive  strips.  The 
wound  should  be  covered  by  a  dressing  while  the  adjacent  area  is  shaved, 
washed,  and  sterilized.  If,  after  the  haemorrhage  is  controlled  and  the 
wound  cared  for,  a  dry  aseptic  dressing  is  applied,  and  the  examination 
of  the  wound  with  a  probe  or  the  finger,  even  though  both  are  steril- 
ized, and  the  irrigation  or  wiping  out  of  its  recesses  be  omitted,  the  most 
important  thing  to  prevent  secoiularij  infection  has  been  done. 

There  are  many  ways  in  which  mechanical  insults  may  do  harm. 
Gross  mechanical  insults  naturally  do  not  favor  wound  repair,  as  they 
produce  new  injuries  and  cause  hiiMnorrhage.  The  effects  of  such  in- 
juries produced  in  treating  wounds  are  rarely  seen  at  the  present  time, 
but  similar  conditions  are  produced  by  muscular  action,  the  separation 
of  the  edges  of  the  wound,  and  by  the  wiping  and  curetting  away  of 
particles  of  dirt.  These  insults  not  only  carry  the  bacteria  into  the 
depths  of  the  wound,  but  also  favor  their  development  by  injuring  the 
tissues. 

Cautious  treatment  of  the  Avouiid,  and  the  application  of  a  firm,  wvW- 
fitting  bandage,  are  most  important  in  the  prevention  of  mechanical 
injury. 

The  eft'eets  of  ehemieal  and  thermal  iiithienees  air  seen  only  wlien 
improper  or  antiquated  methods  are  employed  in  tlie  treatment  of 
wounds.  They  injure  the  tissues,  decrease  their  natural  i-esistanee 
to  bacterial  invasion,  and  produce  conditions  which  favor  the  develop- 
ment and  progression  of  severe  inflammations, 


20  WOUNDS,  THEIR  TREATMENT  AND  REPAIR 

The  Actual  Cautery  and  Caustics  in  the  Treatment  of  Wounds. — The 

effort  to  destroy  completely  the  cause  of  inflammation  or  wound  infec- 
tions led  in  olden  times  to  the  use  of  a  radical  measure  which  we  to-day 
use  little  for  this  purpose — the  hot  iron  or  Ferrum  Candens.  All  caus- 
tics (concentrated  carbolic  acid,  nitric  acid,  and  zinc  chloride)  have  a 
similar  action.  The  foe  is  destroyed,  but  with  it  the  tissue  to  a  great 
extent,  and  for  this  reason  cauterization  is  only  occasionally  employed 
in  the  treatment  of  w^ounds.  It  is  used  most  frequently  in  those  cases 
in  which  there  is  a  highly  virulent  and  dang'erous  infection,  for  example, 
in  wounds  received  during  the  post-mortem  examination  of  fresh  cada- 
vers with  acute  suppurative  or  general  pyogenic  infections  or  anthrax, 
also  in  snake  bites,  hydrophobia,  and  tetanus.  Cauterization  of  the 
wound  is  only  reliable  if  immediate.  If  the  infection  is  caused  by 
highly  virulent  bacteria  with  a  short  period  of  incubation,  or  if  time 
has  been  allowed  for  the  bacteria  to  enter  the  lymph  and  blood,  or  if 
it  does  not  destroy  the  infectious  material,  it  is  dangerous,  for  the 
necrotic  tissue  or  eschar  closes  the  wound,  and  the  inflammatory  exu- 
date forming  behind  it  cannot  find  exit,  and  the  inflammation  spreads 
into  the  tissues. 

This  is  the  reason  why  the  knife  is  better  than  the  cautery,  and  why 
severely  infected  wounds  should  be  excised  as  quickly  as  possible  after 
the  injury.  If  a  tampon  is  applied  after  the  wound  is  excised,  the  dry 
gauze  takes  up  and  removes  the  remaining  infectious  material  by  its 
capillarity,  and  limits  the  spreading  of  the  inflammation  by  the  removal 
of  the  exudate. 

Action  of  Antiseptic  Solution. — The  weaker  the  solution  of  antiseptics 
(two  to  three  per  cent  carbolic  acid,  one  half  to  one  per  cent  bichloride 
of  mercury)  used  for  sterilization,  the  less  the  injury  to  the  tissue;  like- 
wise, the  less  the  effect  upon  bacteria.  The  irrigation  of  a  wound  with 
antiseptic  solution  never  destroys  bacteria ;  it  removes  mechanically  only 
those  lying  superficially  and  attached  to  blood  clots  or  particles  of  dirt. 
Antiseptic  .solutions  never  reach  bacteria  lying  within  or  beloAV  the  layer 
of  fibrin  covering  the  surfaces  of  the  wound,  for  the  antiseptics  form  a 
chemical  compound  with  the  albuminous  wound  secretion  by  which  their 
action  is  reduced  or  destroyed.  The  bacteria  remain,  therefore,  unin- 
fluenced, Avliile  the  resistance  of  the  tissues  is  lowered  or  destroyed. 

Mechanical  Removal  of  Dirt,  Hair,  etc.,  from  Accidental  Wounds. — 
The  cleansing  of  wound  surfaces  with  chemicals  which  are  injurious 
should  be  avoided.  The  grosser  particles  of  dirt  and  hair  should  be 
removed  with  forceps,  blood  clots  with  sterile  gauze,  without  producing 
further  injiiiy.  IMiis  can  be  done  by  gently  irrigating  with  physiological 
salt  solution,  which  is  allowed  to  drop  from  saturated  gauze,  or  more 
thoroughly  with  a  three  or  five  per  cent  solution  of  hydrogen  peroxide. 


THE  TREATMENT  OF  WOUNDS  21 

The  latter,  coming  in  contact  with  blood,  wound  secretion,  or  pus,  liber- 
ates oxj^gen  and  develops  a  white  foam  which,  slowly  rising  from  the 
wound,  removes  all  the  superficial  dirt  with  it  in  the  best  mechanical 
way.  The  solution  has  the  great  advantage  that  it  does  not  injure  the 
tissues,  and  besides  cleansing  controls  capillary  luxnnorrhage.  According 
to  Honsell  the  liberated  oxygen  has  no  bactericidal  action. 

The  use  of  the  cautery  or  of  antiseptics  in  the  treatment  of  infected 
accidental  wounds  may  be  compared  to  the  conduct  of  a  campaign  by  a 
general,  who  devastates  and  damages  his  own  land  to  undo  the  enemy. 
The  aseptic  treatment  of  a  wound,  however  (and  operation-wounds  are 
placed  in  this  category),  attempts  to  destroy  the  invading  foe  by  sparing 
the  tissues,  and  to  produce  conditions  in  which  he  cannot  survive. 

The  Object  of  the  Treatment  of  "Wounds. — The  restoration  of  condi- 
tions favorable  to  wound  repair  is  the  object  of  the  treatment  of  the 
wound.  When  one  considers  all  the  conditions  which  favor  the  develop- 
ment of  bacteria  in  tissues,  it  is  easily  understood  why  the  coagulated 
blood  and  the  necrotic  tissue  (separated  fragments  and  contused  edges 
of  wounds)  must  be  removed,  and  the  wound  secretion  consisting  of 
blood,  lymph,  and  other  exudates  drained  away.  The  former  is  the 
best  culture  medium  for  bacteria ;  the  latter  by  its  accumulation  increases 
the  tension  of  the  tissues  and  drives  the  infectious  materials  into  the 
spaces  of  the  surrounding .  tissues.  Therefore  the  hcemorrhage  should 
be  completely  controlled  and  the  coagulum  removed.  Deep  recesses 
should  be  made  accessible  by  enlarging  the  wound  or  making  counter 
openings.  Contused  and  lacerated  edges  and  surfaces  of  Avounds  should 
be  trimmed  off  smoothly  with  knife  and  scissors.  In  old  w^ounds  the 
crust  composed  of  dried  wound  secretion  should  always  be  removed. 

The  conditions  of  the  wound,  together  with  the  i)()ssil)iliti(\s  of  in- 
fection, determine  whether  it  should  be  sutured  or  tainjioncd  and 
drained. 

Any  incised  wound  may  be  sutured  provided  it  has  not  been  improp- 
erly treated  before  being  seen  by  the  surgeon,  in  which  case  the  possil)ility 
of  infection  must  be  taken  into  consideration.  The  clean-cut  sui'faces  of 
incised  wounds  do  not  provide  conditions  favorable  for  the  retention  and 
growth  of  bacteria.  Some  of  the  bacteria  which  may  have  already  en- 
tered the  wound  are  destroyed  by  the  bactericidal  substances  in  the 
tissue  fluids,  while  others  are  removed  by  the  hjBmorrhage.  In  the  in- 
cised wounds  there  is  no  necrosis,  and  if  the  control  of  the  hannorrhage 
has  been  complete  enough  to  prevent  the  formation  of  a  blood  clot  the 
conditions  are  not  favorable  for  the  development  of  bacteria.  The  same 
conditions  are  present  in  operation-wounds  made  in  tis.sues  which  are 
not  infected. 

Contused  and  lacerated  wounds  should  be  sutured  only  in  exceptional 


22 


WOUNDS,   THEIR  TREATMENT  AND   REPAIR 


\^ 


Interrupted  Suture. 


cases.  If  the  wound  can  be  rendered  elean-cut  or  excised,  it  may  be 
sutured  completely  or  partially,  when  the  accumulation  of  wound  secre- 
tion is  not  feared.  The  lacerated  and  contused  margins  of  the  orifices 
of  the  body  (lips,  nose,  eyelids,  anus,  vagina)  should  be  accurately 
united,  after  the  edges  of  the  wound  have  been  vivified,  to  prevent  dis- 
placement and  distortion.  Other  wounds,  if  the  conditions  are  not  favor- 
able for  sutures,  should  be  treated  by  the  open  method. 

Sutures  and  Technic  of  Inserting  and  Tying. — Interrupted  sutures  of 
silk  or  horsehair  are  used  in  closing  wounds  of  the  skin.  Other  suture 
material,  such  as  silkworm  gut,  catgut,  silver  wire,  is  used  but  little  for 
skin  sutures. 

The  interrupted  suture  is  the  most  important,  as  it  can  be  used  any- 
W'here.  The  method  of  its  application  may  be  seen  in  the  accompany- 
ing figures.  The  sutures  as  a  rule  are 
passed  vertically  to  the  edges  of  the 
wound;  only  in  exceptional  cases,  in 
plastic  surgery,  where  there  is  a  dis- 
placement of  the  skin  edges,  are  they 
passed  obliquely.  Sutures  used  to 
draw  the  tissues  together  under  ten- 
sion are  called  tension  sutures. 
The  following  technic  is  employed  in  the  application  of  the  suture. 
The  border  of  the  wound  is  raised  with  a  toothed  forceps,  and  the  needle 
is  pushed  through  it  some  millimeters  from  its 
edge.  When  tension  sutures  are  applied  the 
needle  should  enter  the  skin  about  two  centimeters 
from  the  edges  of  the  wound.  The  needle  is  then 
pushed  through  the  skin  until  its  point  appears 
in  the  depths  of  the  wound.  The  other  border  is 
then  raised  and  the  needle  is  pushed  from  the 
depths  of  the  wound  through  it.  The  needle 
should  pierce  the  skin  at  the  same  distance  from 
the  edge  as  on  the  opposite  side. 

If  both  ])orders  are  pierced  too  superficially, 
dead  spaces  filled  with  blood  are  formed,  which 
delay  wound  healing.  If  the  borders  are  pierced 
at  too  great  a  distance  from  the  edges  of  the 
wound  and  too  superficially,  the  edges  will  not 
be  approxinuited,  for  one  will  be  turned  in, 
the  other  out  (Fig.  15).  If  in  a  symmetrical 
wound  one  border  is  pierced  deeply,  the  other 

superficially,  the  latter  will  be  turned  in  and  coVered  by  the  former 
(Fig.  16). 


Fig.  14.  —  Elevation  of 
Edge  of  Wound  with 
Rat-tooth  Forcep 
While  Passing  Suture. 


THE  TREATMENT   OF   WOUNDS 


23 


In  superficial  wounds  both  edges  may  be  pierced  at  the  same  time, 
provided  they  are  held  together  with  tissue  forceps  by  an  assistant. 


Fig.  15. 


Fig.  16. 


The  surgical  knot  should  be  tied.  The  necessary  manipulations  may 
be  performed  differently,  and  are  a  matter  of  practice.  The  beginner 
may  practice  with  thick  twine,  tying  knot  after  knot,  until  finally  he 
can  do  so  without  paying  attention  to  it. 


Fig.   17a 


In  tying  a  suture  both  ends  should  be  made  tense  and  held  pai-allel, 
not  crossed,  at  least  a  hand's  breadth  from  the  wound,  as  the  knot  is 
formed  by  carrying  one  end  of  the  suture  twice  around  the  other  end. 


24 


WOUNDS,   THEIR   TREATMENT   AND   REPAIR 


It  is  impossible  to  tie  the  knot  quickly  if  the  s^^ture  is  not  made  tense, 
and  if  tied  too  close  to  the  wound.  This  first  loop  is  tightened  over 
the  wound  until  its  edges  are  approximated.  Better  approximation  of 
the  skin  edges  may  be  secured  if  the  knot  be  not  tied  too  tightly.  The 
ends  of  the  suture  should  then  be  drawn  to  the  side  and  the  knot  dis- 
placed, so  that  it  does  not  rest  on  the  wound ;  a  second  simple  knot  is 
tied.  The  ends  of  the  sutures  must  be  changed  from  one  hand  to  the 
other  while  tying  the  knot,  for  if  they  are  not  a  poorly  placed  "granny 
knot  "  will  be  formed. 

If  any  fat  protrudes  between  the  edges  of  the  skin,  a  superficial 
suture  should  be  placed  at  this  point.  If  the  edges  are  turned  in,  a  deep 
suture  should  be  placed  to  raise  them.  If  the  edges  are  irregular,  the 
inverted  edge  should  be  pierced  by  a  deep  suture  and  the  raised  edge  by 


Fig.  19. 


Fig.  22. 


a  superficial  one  placed  near  the  margin  to  equalize  the  displacement. 
The  same  procedure  should  be  used  when  the  edges  of  a  wound  are  not 
symmetrical. 

The  interval  between  the  separate  sutures  should  be  on  an  average 
about  one  centimeter.  'I'he  sutui-es  should  be  placed  at  greater  intervals 
when,  because  of  ha'mori-hage  or  contusion,  a  large  amount  of  wound 
secretion  is  fcai-cd.  In  wounds  of  the  face,  eyelids,  or  lips,  where  a 
very  accnrnte  approximation  is  demanded,  the  finest  sutui'es  should  be 
used   and   they   should    be   placed   closely    together.      Tlie   advantage   of 


THE   TREATMENT   OF    WOUNDS 


Ztj 


Fig.  23.- 


-CoNTiNuous  Suture  Uniting  Stomach  and 
Intestine. 


the  interrupted  suture  is  that  it  is  easily  applied  under  different  con- 
ditions. 

If  the  skin  and  mucous  membrane  are  cut  at  tjie  same  time,  the 
through  and  through  suture  should  never  be  used,  for  the  mucous  mem- 
brane is  usually  folded 
into  the  wound,  and 
bacteria  from  its  sur- 
face pass  through  the 
stitch  holes.  The  su- 
ture should  be  passed 
through  the  skin  to  the 
mucous  membrane  and 
out  on  the  other  side, 
not  entering  on  the 
mucous  surfaces,  which 
should  be  united  by  a 
separate  row  of  super- 
ficial interrupted  su- 
tures. 

Buried    sutures    of 
absorbable   catgut,    or, 

where  tension  is  to  be  prevented,  of  silk  or  aluminum  bronze  should  be 

used  in  deep  wounds,  where  the  ana- 
tomical relations  of  the  deeper  struc- 
tures are  to  be  restored  or  the  forma- 
tion of  dead  spaces  under  the  skin 
suture  to  be  avoided.  In  these  cases 
layer  sutures  should  be  used ;  for  ex- 
ample, in  closing  an  incision  in  the 
abdominal  wall  the  peritoneum  should  be  sutured'  first,  then  the  fascia? 
and  muscles,  and  finally  the  skin.  Concerning  the  suture  of  complicated 
wounds  (nerves,  ten- 
dons, ^ones,  arteries, 
etc.)  see  Injuries  of 
Soft  Parts. 

The  continuous 
suture  (glover's  or 
M'hip  stitch)  is  about 
the  only  one  of  the 
remaining  methods 
that  is  used  to-day. 

It  is  used  especially  in  intestinal  work,  as  it  may  be  ([uickly  api)lH"d. 
After  the  first  stitch  is  inserted  a  surgeon's  knot  is  tied;  if  the  suture 


f^S^S^^' 


f^=saa^- 


Fig.  24. — Mattress  Suture. 


Fig.  25. — Halsted's  Subcuticular  Stitch. 


26 


WOUNDS,   THEIR  TREATMENT   AND   KErAIR 


is  not  continued  to  the  starting  point  as  in  circular  intestinal  sutures 
and  anastomosis,  the  stitch  is  terminated  by  passing  the  needle  twice 


Fig.  26. — Quili.ed  Suture. 


Fig.  27. — Leaded  Suture. 


under  the  last  loop.    If  so  continued  the  two  ends  of  the  suture  are  tied. 
At  the  point  where  the  sutures  end  and  where  there  is  tension,  inter- 


FiG.  28. — Twisted  Suture. 

rupted  sutures  may  be  applied 
for  safety.  The  mattress,  plaited, 
quilled,  and  harelip  sutures  are  but 
rarely  used.  Ilalsted's  subcuticular 
suture  is  more  often  employed. 

The  TJse  of  Metal  Clamps  and 
Fasteners  to  Close  Wounds. — To  ob- 
viate the  cutting  of  the  skin  which 
occiu-s  from  the  use  of  sutures  dif- 
ferent forms  of  metal  clamps  or 
fasteners  were  introduced  by  Vidal 
and  others.  These  were  applied  to 
the  wound  borders  with  compli- 
cated instruments.  They  can  be  used  only  in  wounds  with  synunetrical 
bord("i-s  wliich  involve  llie  skin,  as  they  do  not  grasp  the  deeper  tissues. 

Dressing  of  a  Sutured  Wound.— The  line  of  suture  should  be  covered 
with  sterile  gauze  by  which  the  oo/ing  tissue  fluids  are  taken  up  and 
di-ied.  The  gau/(>  should  ])e  held  in  place  by  adhesive  plaster  or  col- 
lodion, the  lattei-  being  applied  to  the  edges  of  the  'gauze  and  not  directly 
over  the  wound.     The  direct  application  of  collodion  pastes  or  powders 


Fig.  29.  —  Intestinal  Suture,  a,  Inner 
layer  of  sutures;  b,  outer  layer  of  su- 
tures (serous  layer);  the  inner  sutures 
are  tied;  c,  position  of  the  edges  of  the 
wound  after  tving  botli  layers  of  sutures. 


THE   TREATMENT   OF   WOUNDS 


27 


to  the  wound  (iodoform,  dermatol)  is  not  to  be  recommended,  for  they 
prevent  the  discharge  of  wound  secretion,  resulting:  from  slit,dit  inflam- 
mation or  suppuration  in  a  stitch  hole.  Skin  sutures  should  be  removed 
between  the  fifth  and  eighth  days.  If  silk  sutures  are  allowed  to  remain 
longer  they  act  as  a  foreign  body,  and  bacteria  from  the  skin  invade 
the  tissues  surrounding  them. 

Buried  non-absorbable  sutures  become  encapsulated  in  sterile  wounds. 
If  not  encapsulated,  because  of  mild  infection,  a  narrow  fistula  is  formed 
from  which  the  non-absorbable  suture  of  silk  or  silver  wire  is  discharged, 
if  not  previously  removed  by  a  dilatation  of  the  fistula. 

The  fundamental  difference  between  the  cutaneous  and  the  intes- 
tinal suture  is  that  in  the  former  the  separate  layers  of  the  wound  sur- 
faces are  approximated,  while  in  the  latter  a  broad  approximation  of 
the  serous  coats  must  be  obtained  by  an  inversion  of  tliQ  edges  of  the 
wound.  In  intestinal  work  two  rows  of  sutures  should  be  employed ;  the 
first  should  include  all  the  coats,  or  the  serosa  and  muscularis,  and  is 
ha?m6static;  the  second  the  serosa.     (Fig.  30.) 

Every  wound  of  the  stomach  or  intestine,  even  if  the  laceration  or 
contusion  does  not  extend  into  the  lumen,  should  be  sutured,  because 
of  the  danger  of  perfora- 
tion. Fine  silk  or  Pagen- 
stecher's  celluloid  linen 
are  the  suture  materials 
generally  employed  in  in- 
testinal work. 

Iodoform  Gauze  Tam- 
pon.— If  the  conditions  for 
wound  repair  are  not  fa- 
vorable, as  is  frecpiently 
the  case  in  contused  and 
lacerated  wounds,  the 
open  treatment  with  the 
the  tampon  is  employed 
to  drain  oft'  the  infectious 
material  with  the  wound  secretion  and  to  pi'event,  by  allowing  free  access 
of  air,  the  development  of  anierobic  bacteria  (putrefactive  bacteria,  tet- 
anus bacilli). 

In  gunshot  and  punctured  wounds  the  use  of  sterile  gauze  serves 
a  double  purpose:  (1)  It  drains  away  wound  secretion,  and  (2)  pre- 
vents the  development  of  secondary  infections,  so  that  wounds  of  the 
deeper  structure  may  heal  as  subcutaneous  wounds  without  the  dangers 
of  inflammation.  Iodoform  gauze  is  used  as  an  aseptic  tampon.  (Con- 
cerning its  preparation,  idde  Preparation  of  Aseptic  Dressings.) 


Fig.  30. — The  Internal  Continuous  Suture  Is  In- 
verted  BY   AN   P^XTERNAL   INTERRUPTED   LaYER. 


28  WOUNDS,   THEIR   TREATMENT   AND   REPAIR 

The  iodoform  gau/e  should  be  hiid  upon  the  fresh  wound  or  intro- 
duced into  wound  cavities  with  sterile  instruments  and  gentle  pressure 
made.  After  some  minutes  it  becomes  firndy  attached,  controls  the  haem- 
orrhage, and  removes  from  the  surfaces  of  the  wound  by  its  capillarity 
(capillary  drainage)  blood  and  lymph  exudates,  and  infectious  materials 
(bacteria  and  toxins),  which  are  drained  into  the  dressings,  where  they 
become  dry  and  harmless. 

Iodoform  gauze  has  but  little  antiseptic  action,  and  this  action  is 
not  exerted  upon  the  bacteria  in  the  wound,  but  upon  those  drawn  up 
into  the  gauze.  The  use  of  iodoform  gauze  can  therefore  be  looked  upon 
as  an  aseptic  method  of  wound  treatment. 

"When  used  as  a  tampon  the  gauze  should  be  placed  in  all  the  recesses 
of  the  wound.  In  small  gunshot  and  punctured  wounds,  the  gauze 
should  merely  be  laid  over  the  wound  and  not  forced  into  the  tract,  as 
in  this  way  a  secondary  infection  might  be  produced.  Large  and  deep 
Avounds  with  cavities,  such  as  are  produced  in  gunshot  wounds  by  the 
explosive  force  of  the  projectile  (dum-dum),  should  be  covered  with 
layers  of  iodoform  gauze  and  the  remaining  spaces  filled  with  sterile 
gauze  to  avoid  the  use  of  too  nnich  iodoform  and  resulting  iodoform 
intoxication.  If  the  deepest  point  of  the  wound  is  not  favorably  situated 
for  capillary  drainage,  the  tampon  is  often  combined  with  tubular  drain- 
age, counter-openings  frequently  being  required  for  this  purpose. 

In  many  cases  the  tampon  must  be  sutured  in  position  to  prevent  its 
displacement  (in  the  buccal  cavity,  pharynx,  larynx,  also  in  the  abdom- 
inal cavity). 

[Cigarette  drains  are  used  very  extensively  in  surgical  work  at  the 
present  time.  In  preparing  such  a  drain  the  gauze  is  loosely  rolled  until 
the  size  recpiired  is  prepared.  The  gauze  is  then  wrapped  in  a  layer 
of  gutta  porcha  and  the  drain  is  ready  for  use.  The  size  of  cigarette 
drains  usuallj^  employed  corresponds  to  that  of  the  little  and  ring  fingers. 
If  it  is  desirable,  tubular  drainage  may  be  combined  with  the  capillary 
drainage  in  a  cigarette  drain,  a  piece  of  small  rubber  tubing  being  in- 
closed in  the  gauze.  The  advantage  of  the  cigarette  drain  is  that  it 
can  be  easily  removed  from  wounds  without  causing  pain  and  injuring 
granulating  surfaces,  and  it  acts  as  efficiently  as  unprotected  iodoform 
gauze  packed  into  a  wound.  Iodoform  or  plain  gauze  may  be  used  in 
the  preparation  of  the  cigarette  drain.] 

The  rapid  reduction  of  the  number  of  bacteria  in  infected  wounds 
and  the  prevention  of  progressive  inflammations  are  usually  due  to  the 
capillarity  of  iodoform  gauze. 

Moist  Dressings. — The  number  of  bacteria  in  a  wound  rapidly  in- 
creases when  a  moist  tampon  or  dressing  is  used,  for  example,  if  gauze 
saturated  with  antiseptic  solutions  is  placed  in  or  upon  a  wound  (Gon- 


THE   TREATMENT   OF    WOIWD.S  29 

termann).  The  treatment  with  moist  compresses,  evaporation  from 
which  is  prevented  by  rubber  tissue  or  paraffin  paper,  should  be  dis- 
carded for  this  reason.  The  bacteria  multiply  not  only  in  the  wound, 
but  also  in  the  gauze,  in  spite  of  the  fact  that  it  contains  antiseptics 
and  spread  to  the  surrounding  sldn  and  invade  the  infection  atria  caused 
by  maceration,  producing  pustules,  furuncles  or  lymphangitis.  The  con- 
ditions within  a  moist  dressing,  evaporation  from  which  is  prevented, 
have  rightly  been  compared  to  those  of  an  incubator,  and  Schlange  hfis 
demonstrated  how  bacteria  will  penetrate  all  the  layers  of  a  gauze  dress- 
ing, evaporation  from  which  has  been  prevented,  while  in  dry  aseptic 
gauze  they  are  unable  to  multiply  as  a  result  of  the  drying  of  the 
secretion. 

On  the  other  hand,  moist  dressings  uncovered  by  rubber  tissue  and 
permitted  to  evaporate,  accjuire  a  strong  capillary  action.  Of  course  this 
action  begins  later  in  moist  than  dry  dressings,  which  begin  to  absorb 
as  soon  as  applied.  The  capillarity  of  unprotected  moist  dressings  is 
not,  however,  as  Notzel  thinks,  greater  than  the  dry.  A  greater  number 
of  bacteria  may  be  found  in  the  moist  dressings  than  in  the  dry  after  a 
time,  but  the  bacteria  multiply  in  the  former. 

For  this  reason  we  prefer  the  dry  dressing,  or  tamponade,  to  the 
moist  in  the  treatment  of  infected  wounds,  such  as  acute  suppurative 
inflammations  (vide  General  Rules  for  the  Treatment  of  Pyogenic  In- 
fections), and  only  use  the  moist  evaporating  dressings  in  the  treatment 
of  wounds  from  which  is  discharged  a  thick  secretion,  or  where  there 
is  necrosis  and  the  separation  of  the  dead  tissue  is  to  be  favored.  In 
these  eases  the  irritation  of  the  antiseptic  (preferably  a  three  per  cent 
solution  of  aluminum  acetate)  increases  and  thins  the  secretion,  cleanses 
the  surface,  and  hastens  the  formation  of  granulation  tissue. 

fin  America  warm  moist  dressings  of  a  saturated  solution  of  l)()i'ic 
acid  are  used  very  extensively  in  the  treatment  of  infected  wounds,  and 
clinical  experience  seems  to  show  that  they  have  a  very  favorable  intiu- 
ence.] 

Alcohol  Dressings. — An  alcohol  compress  is  a  good  agent  for  cleansing 
wounds  and  infected  granulating  surfaces  if  evaporation  is  not  prevented 
by  rubber  protective.  The  growth  of  bacillus  pyocyaneus  ceases  if  such 
a  compress  is  applied  three  or  four  times,  during  a  period  of  twenty- 
four  hours.  On  the  other  hand,  alcohol  compresses  covered  with  rubber 
protective  may  cause  gangrene,  such  as  fre(iuently  follows  the  use  of  car- 
bolic acid  and  lysol  compresses  (with  or  without  evaporation). 

Carholic  Acid  Compresses  and  Carbolic  Acid  Gangrene. — The  moist 
carbolic  acid  compress  and  dressing  is  often  used  by  the  laity  as  a 
prophylactic  measure  against  inflammation  in  accidental  wounds.  The 
harmful  action  of  the  antiseptic  is  best  seen  in  eases  where  the  dressing 


30 


WOUNDS,    THEIR   TREATMENT   AND    REPAIR 


has  been  allowed  to  remain  some  time,  when  not  only  the  wound  surfaces, 
but  also  the  skin  and  deeper  lying  tissues  may  be  affected.     Numbness 

may  follow  after  a  short  time  the  application  of 
the  compress ;  this  numbness  may  later  pass  into 
complete  amesthesia.  If  the  treatment  is  dis- 
continued at  this  time,  recovery  with  necrosis  of 
the  epithelium  only  may  occur.  After  a  longer 
application,  and  even  with  a  one  per  cent  solu- 
tion after  twenty-four  hours,  the  whitish  discol- 
oration of  the  skin  may  pass  into  the  black  of 
necrosis — the  tissues  in  contact  Avith  the  car- 
bolic acid  becoming  mummified.  The  necrosis 
of  the  skin  is  limited  to  the  area  in  contact  with 
the  dressing.  Frequently  in  the  fingers  and  toes 
the  necrosis  extends  deeper,  involving  tendons, 
joints,  and  bones,  and  the  entire  digit  dies  and 
must  be  amputated. 

The  TJse  of  Iodoform  Gauze  to  Stimulate  the 
Formation  of  Granulation  Tissue  and  Adhesions. 
— The  use  of  iodoform  gauze  is  not  limited  to 
wounds  from  which  infectious  materials  are  to 
be  drained  away  or  haemorrhage  controlled. 
The  stimulating  action  of  iodoform  causes  a 
rapid  development  of  granulation  tissue  'after 
the  tampon  has  been  in  position  some  days,  and 
the  formation  of  adhesions  in  serous  cavities, 
which  are  of  great  surgical  importance.  By  it 
infiammatory  foci  are  walled  off  from  healthy 
serous  surfaces,  and  for  this  reason  the  tampon 
is  often  applied  some  days  before  deep  ab- 
scesses (lung  abscess  or  deeply  situated  abdominal  abscess)  are  opened,  or 
where  the  perforation  of  a  contused  part  of  the  stomach  or  intestine  or 
suture  line  is  feared.  During  operations  a  tampon  of  iodoform  gauze 
placed  about  the  point  of  opening  of  an  abscess  or  the  point  of  incision 
of  an  intestinal  loop  protects  the  adjacent  area  from  infection  with 
I)us  and  fa'ces.  Iodoform  gauze  is  usually  em}^loyed  in  the  form  of 
doiil)le(l  strips,  20  cm.  in  width.  These  can  be  used  for  practically  all 
purposes. 

The  von  Mikulicz  Drain. — Yoii  INliknlicz  iiitroduccnl  into  abdominal 

surgeiy    the    Mikulicz   1iiiii|)()ii    or    dfaiii,    a    hirge    (|iia(lraiigular    ])iece 

of  gauze,  the  center  of  wliich  is  invnginatrd  to  form  a  pouch  which  may 

be  filled  with  sterile  gauz(!  or  drainage  tubes,  as  "the  case  demands. 

The  length  of  time  that  an  iodoform  gauze  tampon  should  be  allowed 


Fig.  31.  —  Carbolic  Acid 
Gangrene  of  the  Great 
Toe,  Following  the  Ap- 
plication OF  A  Compress 
Saturated  "svith  a  Two 
Per  Cent  Solution  of 
Carbolic  Acid  for 
Twenty  -  four  Hours. 
Compress  applied  to  a 
small  lacerated  wound. 


THE  TREATMENT   OF   WOUNDS  31 

to  remain  i)t  situ  depends  upon  the  condition  of  the  Avonnd  and  the 
])ui'pose  for  which  it  has  been  applied.  In  fresh  wounds  it  may  be 
removed  after  a  few  days,  and  if  conditions  are  favorabh^  the  wound 
may  be  sutured.  If  the  tampon  has  been  used  to  control  a  severe  haem- 
orrhage (e.  g.  in  haemophilia,  or  wounds  of  plexuses  or  sinuses)  it  should 
be  removed  only  after  it  has  been  loosened  by  the  secretion  of  the  granu- 
lations. In  serous  cavities  in  which  adhesions  are  to  lie  pi-oduccd,  the 
tampon  must  remain  at  least  a  week. 

In  wounds  which  secrete  thick  pus  or  are  beginning  to  granulate-, 
and  after  incision  of  acutely  inflamed  tissues,  the  iodoform  gauze  should 
be  replaced  by  moist  compresses  which  are  not  covered  by  rublx'r  tissue. 
The  compress  should  be  made  of  several  layers  of  gauze  saturated  with 
three  per  cent  aluminum  acetate,  two  per  cent  boric  acid  solution  or  sixty 
per  cent  alcohol,  and  should  be  evenly  applied. 

In  some  cases  ointments  may  also  be  used.  Layers  of  gauze  eveidy 
arranged  should  be  spread  with  a  mildly  stinuilating  or  indill'erent  oint- 
ment (mercury,  zinc,  borated  vaseline,  or  lanolin)  and  then  applied  to 
the  wound. 

Iodoform  Intoxication. — Iodoform  gauze  may  give  rise  to  unpleasant 
local  and  dangerous  general  after  effects.  These  occur  rarelj^  and  then 
most  freriuently  in  patients  with  an  idiosyncrasy,  or  where  an  excessive 
amount  of  iodoform  has  been  used.  The  so-called  iodoform  eczema  rap- 
idly spreads  from  the  wound  over  an  extensive  area,  and  is  accompanied 
b}^  the  formation  of  vesicles  and  severe  itching.  The  edges  of  the  wound 
become  swollen  and  its  surfaces  coated.  The  itching  may  be  controlled 
by  zinc  oxide  ointment,  and  in  most  cases  the  healing  is  complete  within 
a  week.  The  patient's  attention  should  be  drawn  to  this  fact,  so  that  in 
later  treatment  the  attention  of  the  physician  may  be  direeted  to  this 
idiosyncras3\  Much  more  dangerous  is  the  rare  iodoform  intoxication, 
which  may  develop  even  after  careful  use  of  the  drug.  It  is  causi>d  by 
the  absorption  of  the  decomposition  products  of  iodofoiin  and  oeeucs 
most  frequently  when  iodoform  is  used  in  deep  wounds  which  have  not 
been  protected  from  putrefactive  infections  (operations  about  rectum) 
and  in  wounds  in  which  the  reduction  processes  cause  a  i-api<l  deeoiiiiHi- 
siticm  of  the  iodoform. 

The  symptoms  in  the  l)eginning  or  in  mild  cases  are  persistent  nausea, 
vomiting,  and  headache.  These  usually  rapidly  subside  when  the  gauze 
is  removed.  In  severe  cases  the  symptoms,  consisting  of  psychical  dis- 
turbances, maniacal  excitement,  and  delirium,  are  rapidly  progressive, 
and  are  often  accompanied  by  a  cardiac  weakness  which  may  ]-trove  fatal. 
The  urine  contains  iodine;  often  albumen  and  blood. 

The  danger  of  iodoform  intoxication  and  the  unpleasant  odor  of  the 
powder,  which  is  increased  to  an  unpleasant  garliclike  odor  by  its  de- 


32 


WOUNDS,   THEIR  TREATMENT   AND   REPAIR 


Fig.  32. 


Rubber  Drain.^ge  Tube,  Thread 
Fastening. 


composition  when  coming  in  contact  with  metal  (tracheotomy  tube,  where 
the  dressing  comes  in  contact  with  eating  utensils  in  wounds  of  the 
hand),  have  led  to  the  preparation  and  introduction  of  a  number  of  sub- 
stitutes. These  may  be  divided  into  those  which  contain  iodine,  such  as 
airol,  aristol,  europhen,  iodol,  iodoformal,  iodoformin,  loretin,  nosophen, 
sozoidol,  vioform,  etc.,  and  into  those  which  do  not,  such  as  alumnol, 
amyloform,  dermatol,  thioform,  xeroform,  etc.  The  great  number  indi- 
cates how  little  satisfaction  these  substitutes  have  given,  although  some 
have  found  ardent  supporters. 

Tubular  Drainage. — The  drainage  of  a  wound  with  glass  or  rub- 
ber tubes   provided  with   lateral  openings  to  permit   of  the  escape  of 

wound  secre- 
tion is  called 
tubular  drain- 
age in  contradistinction  to  the 
capillary  drainage  obtained 
by  the  tampon.  Tubes  should 
be  so  placed  in  deep  wounds 
as  to  render  easy  the  escape 
of  secretions  from  any  of 
their  parts.  The  outer  end  of 
the  drainage  tube  should  be 
provided  with  a  sterilized  safety  pin  or  with  a  silk  suture,  which  should 
be  fastened  to  the  skin  with  adhesive  plaster.  In  this  way  the  tube  may 
be  prevented  from  slip- 
ping into  the  wound. 
The  pressure  of  the  safe- 
ty pin  may  be  avoided 
by  placing  gauze  between 
it  and  the  skin.  Often 
the  drainage  tube  and 
tniiipon  are  combined. 
in  tliis  way  the  tube  may  be  retained  in  jiosition  better  and  the  wound 
kept  open. 

Drainage  tubes  should  not  be  allowed  to  remain  in  position  longer 
than  a  few  days.  Their  lumina  easily  become  occluded  by  disintegrated 
blood  clots  and  pus.  AVheu  tlie  dressings  are  changed  new  rubber  drains 
should  be  inserted,  glass  tul)es  should  ])e  n^noved,  and  sterilized  by  boil- 
ing. As  soon  as  the  secretion  diminishes  and  granulations  become  abun- 
dant, the  drain  may  be  gradually  shortened,  and  finally  removed. 

Removal  and  Encapsulation  of  Foreign  Bodies.— Finnlly  the  removal 
or  encapsulation  of  a  foreign  body  ni"st  be  con^^idered  in  the  care  and 
treatment  of  a  wound. 


yfjSS^aW^y 


Fig.  33. — Rubber  Drainage  Tube,  Pin  Fastening. 


THE  TREATMENT   OF   WOUNDS  33 

All  visible  particles  of  dirt  and  forei.un  bodies  should  be  removed 
from  the  wound  witli  tissue  or  dressing  forceps.  If  allowed  to  remain 
wound  repair  will  be  prolonged  by  suppuration. 

A  different  problem  confronts  us  when  we  consider  the  removal  of 
deeply  penetrating  foreign  bodies,  such  as  needles,  fragments  of  glass, 
wood  and  bombs,  broken-off  points  of  knives,  swords,  and  daggers,  bullets 
with  accompanying  pieces  of  clothing,  ])ieces  of  a  metal  helmet,  etc. 
According  to  the  experiments  of  ]\lessner,  Brunner,  and  others,  the  bac- 
teria upon  a  bullet  or  carried  from  the  surface  of  the  skin  are  rarely  of 
the  highly  pathogenic  variet3\  The  experience  of  von  Bergniann  in  the 
Kusso-Turkish  war  has  become  highly  significant  in  the  treatment  of 
bullet  wounds,  both  in  military  and  civil  practice.  He  demonstrated 
that  bullet  wounds  might  pursue  a  perfectly  normal  clinical  course,  in 
spite  of  encapsulation  of  the  bullet,  if  dry  aseptic  dressings  were  ap- 
plied and  the  wound  protected  from  secondary  infections  frequently 
introduced  by  probing,  irrigation,  etc.  The  primary  infections  of  the 
tract  of  the  wound  are  usually  trivial  and  limited  to  its  outer  parts,  and 
the  bactericidal  properties  of  the  tissues  overcome  them. 

Tetanus,  putrefactive  and  suppurative  inflanunations  may  follow  the 
penetration  of  a  foreign  body.  In  these  cases  the  foreign  body  (e.  g.  a 
splinter  of  wood)  has  almost  always  rough  surfaces,  to  which  a  great 
number  of  bacteria  are  attached.  Inflammation  may  develop  about  an 
encapsulated  foreign  body  after  some  years  if  the  connective  tissue  cap- 
sule surrounding  the  foreign  body  and  the  bacteria  carried  in  with  it 
are  ruptured  by  a  trauma  or  if  bacteria  are  deposited  from  the  blood 
in  the  scar. 

Indications  and  Contraindications  for  the  Femoral  of  Foreign 
Bodies. — Clinical  experience  has  established  the  following  fundamental 
principles  in  the  treatment  of  penetrating  foreign  bodies. 

Foreign  bodies  should  be  removed : 

1.  If  they  are  visible  in  the  wound. 

2.  If  the  foreign  body,  such  as  a  sp]int(>r  of  wood,  has  rough  surfaces, 
and  is  frequently  followed  by  inflanunation  or  tetanus. 

3.  If  the  foreign  body  can  be  felt  directly  beneath  the  skin  and  its 
removal  is  a  trivial  procedure. 

4.  If  the  foreign  body  immediately,  or  later  after  being  displaced 
by  muscular  action,  presses  upon  or  is  situated  within  a  nerve,  if  it 
irritates  mucous  or  synovial  membranes,  or  causes  pain  by  its  point  or 
sharp  surface  when  pressed  upon  during  movement  (as  needle,  frag- 
ment of  glass,  etc.). 

5.  If  a  phlegmon  or  tetanus  develops  in  the  tissue  surrounding  the 
tract  of  the  foreign  body. 

Unless  there  are  positive  indications  no  effort  should  be  made  to 
4 


34  WOUNDS,   THEIR  TREATMENT   AND   REPAIR 

locate  the  foreign  body  with  a  probe  or  remove  it  with  forceps,  as  there 
is  danger  of  introducing  secondary  infection.  Incisions  for  the  removal 
of  foreign  bodies  should  be  made  some  distance  from  the  wound  if  it  is 
infected  or  should  be  delayed  until  healing  has  occurred. 

The  position  of  metallic  foreign  bodies  and  glass  may  be  accurately 
determined  by  the  use  of  the  X-ray,  at  least  two  views  from  different 
known  angles  being  necessary.  Information  can  also  be  gained  by  pal- 
pation, location  of  the  pain,  and  the  disturbance  of  function. 

Encapsulation  is  to  be  encouraged  in  all  cases  in  which  the  foreign 
body  is  smooth  and  deeply  situated,  gives  rise  to  no  disturbance,  and  in 
which  there  is  no  inflammation  of  the  tract  of  the  wound. 

If  after  encapsulation  there  is  pain  or  interference  with  function,  the 
benefits  to  be  derived  from  an  operation  are  to  be  carefully  weighed 
against  the  gravity  and  dangers  of  the  same  (for  example,  foreign  body 
in  the  brain  or  vertebral  column  or  in  the  thorax). 

The  most  important  rules  for  the  treatment  of  accidental  wounds 
may  be  shortly  summarized  as  follows: 

Emergency  Dressing. — Immediate  covering  of  the  wound  with  dry 
sterile  gauze. 

Definitive  Dressing. — Cover  the  wound  with  sterile  gauze  while  the 
surrounding  area  is  being  sterilized.  If  ha?morrhage  is  severe,  apply 
Esmarch's  elastic  constrictor.  Preparation  of  area  about  wounds,  the 
same  as  the  field  of  operation  in  an  aseptic  procedure.  Cover  the  sur- 
rounding area  with  sterile  towels.  Ana\sthesia  if  necessary  and  not  con- 
traindicated.  Cautious  separation  of  the  edges  of  the  wound  with  re- 
tractors to  permit  of  inspection.  Removal  of  dirt  and  foreign  bodies 
with  forceps,  of  blood  clots  with  gauze.  Irrigation  of  dirty  wounds  with 
a  three  per  cent  solution  of  hydrogen  peroxide,  application  of  artery 
forceps  and  ligation  of  vessels,  removal  of  fragments  of  tissue,  trimming 
oft'  of  contused  inlges  of  wounds,  tampon,  drainage  or  suture,  dry  aseptic, 
and  immobilizing  dressing. 

LiTKUATU HE.— Bass.  Erfolge  unci  Gefahren  der  Gclatineai)]ilikati()n.  Zontralbl. 
f.  <1.  (ircMzg(!l)iete,  1904,  p.  818. — Bierjreund.  Ueber  deii  llanioglohiDgehalt  bei  chir. 
Erkrankimgen,  mit  besonderer  Riicksicht  auf  den  Wiederersatz  von  Blutveilusten. 
Chir.-Kongr.  Verhandl.,  1890,  II,  p.  159. — Brunner.  Ueber  die  Infektion  der  Schuss- 
v/unden  durch  mitgerisscne  Kleiderfetzen.  Korresp.-Blatt  f.  Schweiz.  Aerzte,  Bd.  26, 
1896. — V.  Efstnarch.  Ueber  kiinstlicbe  Blutleere.  Chir.-Kongr.  Verhandl.,  1896,  II, 
]).  1. — Go  liter  man  II.  Experim.  Untersuchungen  iiber  die  Ab-  oder  Ziinahine  der  Keime 
in  einer  aocidcntellen  Wunde  untor  rein  ascptischer  trcK-koner  u.  antiseptischer  feiichter 
Behandhuig.  Arch.  f.  klin.  Chir.,  Bd.  70,  1!)0.3. — Hctle.  Ueber  die  antiseptische 
Wirkungdcs  Jodofonns.  Chir.-Kongr.  Verhandl.,  IHO,'!,  II,  j).  37(). — lloivscll.  Experim. 
n.  klin.  Untersuchungen  iiber  die  Verwendbarkeit  des  WassenstoffsuiJcroxydes.  Bc^tr. 
z.  klin.  Chir.,  Bd.  27,  1900,  p.  127.— yl.  Kohler.  Transfusion  u.  Infusion  seit  1830. 
Gedenkschr.  f.  v.  Leuthold.  Berlin,  1906,  Bd.  2,  p.  271 . — Kronecker  u.  Sander.  Bemerk. 
iiber  lebensrettende  Transfusion  von  anorgan,  Kochsalzlosung.     Berlin,  klin.   VVochen- 


WOUND   REPAIR  35 

schr.,  1879,  No.  52. — Kultner.  Zur  Frage  des  kiinstlichen  Blutersatzes.  Chir.-Kongr. 
Verhandl.,  1903,  I,  p.  24; — 1st  die  pliysiol.  Kochsalzlusung  durch  die  Tavelsche 
Sodasalzlosung  zu  ersetzen?  Beitr.  z.  klin.  Chir.,  Bd.  35,  1902,  p.  272. — Landois. 
Blutverlust,  Transfusion.  Lehrb.  d.  Physiol,  d.  Menschen. — Leonpacher.  Ueber 
Kochsalzinfusion.  Mitt,  aus  d.  Grenzgebieten,  Bd.  6. — Lossen.  Die  Bluterfaniilie 
Mampel.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  75,  1905,  p.  1. — Mediziudlahteiluiuj  des  k. 
preuss.  Kriegsministeriums,  Ueber  the  Wirkung  u.  kriegschir.  Bedeutung  der  neuen 
Handfeuerwaffen,  Berlin,  1894. — Messner.  Wird  das  Geschoss  (lurch  die  ini  Gewehrhiuf 
stattfindende  Erhitzung  sterilisiert?  Miinch.  med.  Woch.,  1892,  j).  401. — Ndtzcl. 
Experim.  Studie  zum  autisept.  Wundverband.  Arch.  f.  klin.  Chir.,  Bd.  71,  1903,  p.  165. 
— Perman.  Die  Angiotripsie  in  der  operativen  Chirurgie.  Zentralbl.  f.  Chir.,  1904,  p. 
1098. — Pjuhl.  Ueber  die  Infektion  der  Schusswunden  durch  mitgerissene  Kleiderfetzen. 
Zeitschr.  f.  Hygiene,  Bd.  13,  1893,  p.  487. — Schimnielbusch.  Anleitung  zur  asept. 
Wundbehandlung,  Berlin,  1893. — Schlange.  Ueber  sterile  Verbandstoffe.  Chir.- 
Kongr.  Verhandl.,  1887,  II,  p.  141. — Stempel.  Die  Hiimophilie.  Zcntr.  f.  Grenzgebiete, 
1900,  No.  18. — -Strubell.  Der  Aderlass,  Sammelreferat  mit  Lit.  Zentr.  f.  CJronzgcbiete, 
1903,  p.  1. — Zlmmermann.  6  Fiille  von  Hautgangran  uach  subkutaner  Infusion  von 
Kochsalzlosung.     I.-D.  Tiibingen,  1900. 


CHAPTER    III 

WOUND    REPAIR 

There  are  two  methods  of  wound  healincr.  If  the  surfaces  and 
edges  of  wounds  are  closely  approximated  or  held  in  contact  by  sutures 
union  occurs  within  a  few  days.  If,  on  the  other  hand,  the  wound  gapes 
or  there  is  an  actual  loss  of  substance,  new  tissue  must  be  formed  to 
fill  in  the  defect.  The  covering  of  this  ncAV  tissue  with  epithelium  com- 
pletes the  process  of  healing.  Healing  by  the  first  method  is  called 
primary  wound  healing-  or  healing:  per  pvimmn  intenUoncm  ;  by  the  sec- 
ond method,  secondary  wound  healing:  or  healing  per  secut\<J<im  iiiien- 
tie>)um. 

Primary  Wound  Healing. — Primary  healing  occurs,  if  not  prevented 
by  suppurative  inflannnation,  necrosis,  or  the  exudation  of  blood,  when 
the  edges  of  the  wound  are  approximated.  The  union  of  a  superficial 
incised  wound  or  of  a  sutured  wound  requires  from  a  week  to  ten  days. 
When  the  crust  which  covers  the  line  of  union  and  the  desquamated 
epithelium  of  the  edges  of  the  wound  fall  off,  a  delicate  reddish  epithelial 
membrane  covering  the  space  between  the  edges  of  the  w(unid  is  seen. 
Cradually  the  newly  formed  epithelium  cornifies  and  the  (inn.  rcnl  sear 
becomes  soft  and  Avhite.  The  white  color  and  smooth  surface  of  the  scar 
are  permanent.  Only  very  superficial  scars  disappear  completely  after 
some  years. 


36 


WOUNDS,    THEIR   TREATMENT    AND    REPAIR 


Primary  wound  healing  is  more  complete  and  rapid  if  the  edges  of 
the  wound  are  accurately  approximated,  but  even  then  it  is  a  compli- 
cated process.  Only  in  wounds  of  the  epithelium  do  we  find  a  direct 
union  of  the  edges  by  newly  formed  cells  which  replace  those  injured 
and  destroyed.  In  all  vascular  tissues  such  a  union  by  simple  regenera- 
tion is  impossible.  Blood  and  tissue  fluids  which  are  poured  out  into  the 
wound  prevent,  even  in  smallest  amounts,  the  approximation  of  the 
wound  edges,  and  besides,  in  all,  even  incised  wounds,  the  tissues  are 
injured  considerably  by  the  trauma,  and  whole  groups  of  cells  are  de- 
stroyed by  the  subsequent  circulatory  and  nutritional  disturbances,  by  the 
exposure  to  the  air,  and,  if  the  wound  has  been  improperly  treated,  by  the 
contact  with  water  and  antiseptics. 

The  accumulation  of  blood  and  tissue  fluids  and  the  death  of  tis- 
sues prevent  a  direct  union,  but  incite  processes  which  provide  for  heal- 


FiG.  .34. — IsoLATKD  Cki-i.s  fkom  Ghanui.ation  Tissue,  a,  L3anphocytes  or  mononuclear 
leucocytes;  b,  different  forms  of  mononuclear  connective  tissue  cells;  c,  polynuclcar 
connective  tissue  cells;  d,  connective  tissue  cells  forming  fibrilhi';  e,  fully  developed 
connective  tissue.      (After  Ziegler.) 


ing  of  the  Avound.  The  irritation  resulting  from  the  trauma,  secondary 
injuries,  and  degenerating  cell  ma.sses  gives  rise  to  the  symptoms  of 
inflammation  wliich.  because  of  its  etiology,  is  known  a.s  mechanical  or 
iraumalic  inHaiinnation. 

During  this  stage  the  edges  of  the  Avound  become  united  by  a  layer 
of  fi])r-in  Avhicli  is  formed  by  the  coagulation  of  the  blood,  lymph  and 
wound  secretion.  (Agglutination  is  the  first  step  in  primary  wound 
healing;  the  earlier  it  begins,  the  more  rapid  and  complete  the  union.) 


WOUND   REPAIR 


•a: 


Even  when  a  wound  heals  by  primary  union,  granulation  tissue,  the  ger- 
minal tissue  which  fills  in  the  defect,  is  formed,  but  in  miiiiinal  amounts. 
During  the  process  of  agglutination  the  neighboring  blood   vessels 
become  congested.     There  is  a  peripheral  stasis  and  emigration  of  leuco- 


FiG.  3o. — Healing  of  a  SrxrRED  Incised  Wound  of  the  Skin  Six  Days  Old.  (After 
Ziegler.)  a,  Epidermis;  b,  corium;  c,  fibrinous  part  of  tlie  exudate;  d,  newly  formed 
epidermis  which  contains  numerous  karyokinetic  figures  and  epithelial  processes  which 
have  penetrated  the  exudate  beneath  it;  e,  karyokinetic  figures  in  the  epithelium 
somewhat  removed  from  the  line  of  incision;  /,  germinal  tissue  developing  from  tlie 
connective  tissue  which  also  contains  proliferating  vessels;  g,  proliferating  germinal 
tissue  with  leucocytes;  h,  groups  of  leucocytes  in  the  inner  part  of  the  wound;  i, 
fibroblasts  lying  in  the  exudate;    k,  .sebaceous  glands;   I,  sweat  glands. 


eytes,  and  some  exudation,  which  assists  in  the  formation  of  the  fibrin 
layer.  The  accumulation  of  polymorphoiuiclear  leucocytes,  which  r:\n 
be  demonstrated  in  from  three  to  four  hours,  is  well  marked  in  twenty- 
four  hours  (Marehand).  The  number  of  leucocytes  in  the  wound  de- 
pends upon  the  amount  of  injury  and  degeneration. 

Functions    of    Leucocytes. — These    cells    perform    many    functions. 
They  secrete  a  ferment  which  digests  albumen  and  liquefies  the  degener- 


38  WOUNDS,   THEIR  TREATMENT   AND   REPAIR 

ating  tissues  and  they  produce  bactericidal  bodies,  which  destroy  the 
pathogenic  bacteria.  The  hitter  are  attenuated  in  aseptic  operation-  and 
accidental  wounds  (Schloft'er,  Riggenbach,  Brunner).  Leucocytes  have 
phagocytic  properties  also.  Their  protoplasm  is  motile,  and  they  are  able 
to  surround  and  ingest  particles  of  tissue  and  the  products  of  degenera- 
tion. The  young  fixed  tissue  cells  (tissue-phagocytes  or  macrophages) 
rich  in  protoplasm  are  more  actively  phagocytic  than  the  leucocytes. 
These  ingest  fat  and  pigment  granules  and  become  transformed  into  the 
so-called  fat  or  pigment  granule  globules,  which  may  pass  through  the 
lymph  stream  into  the  glands.  The  leucocytes  rapidly  degenerate  and 
are  replaced  by  new  cells ;  often  they  are  found  in  the  cytoplasm  of  the 
large  phagocytes. 

Proliferation  of  Fixed  Tissue  Cells. — The  proliferation  of  the  fixed 
tissue  cells  goes  hand  in  hand  with  the  changes  above  described.  Nu- 
merous karyokinetic  figures  indicate  the  activity  of  growth  in  the  deep 
layers  of  the  epithelium,  in  the  endothelium  of  the  vessels,  and  in  the 
fixed  tissue  cells.  Large  cells  of  different  forms  with  one,  two,  or  many 
nuclei  (the  latter  are  called  giant  cells)  grow  from  the  tissues  into  the 
wound  cleft.  These  cells  are  the  formative  connective  tissue  cells  and 
are  called  fibroblasts.  They  infiltrate  the  agglutinating  layer  of  fibrin, 
and  later  form  the  fibrillse  of  the  new  connective  tissue,  which  holds  the 
edges  of  the  wound  together  and  is  known  as  a  scar. 

Formation  of  New  Blood  Vessels. — This  connective  tissue  is  composed 
not  only  of  fibroblasts,  but  also  of  leucocytes,  lymphocytes,  and  plasma 
cells  (vide  Liflammation,  Part  II).  The  formation  of  new  blood  vessels 
accompanies  the  proliferation  of  fixed  tissue  cells,  and  is  the  result  of 
the  actual  sprouting  of  solid,  arched,  protoplasmic  processes  from  the 
walls  of  preexisting  vessels.  These  protopla.smic  processes  later  become 
united  with  each  other,  and  their  interior  becomes  liquefied,  hollow,  and 
patent. 

Time  Kcqiiired  for  Healing  of  Clean  Incised  Wound. — A  clean-cut 
wound  with  an  undisturbed  clinical  course  heals,  as  a  rule,  in  about 
one  M'eek  or  ten  days.  With  the  development  of  the  fibrillar  ground 
substance,  the  newly  formed  scar,  which  in  the  beginning  is  vascular 
and  rich  in  cells,  contracts.  It  becomes  paler  and  narrower.  The  firm- 
ness of  the  scar  is  gradually  lost  as  the  newly  formed  connective  tissue 
bundles  separate.  The  scar  can  be  distinguished  microscopically  from 
the  surrounding  tissue  for  some  time  by  its  firmer  texture  and  by  the 
absence  of  elastic  fibers.  The  less  the  amount  of  injury,  and  therefore 
the  less  the  inflannnation,  the  finer  and  more  nearly  perfect  the  scar 
will  be.  Broader  and  more  resistant  scars  remain  after  the  primary 
healing  of  contused  and  lacerated  wounds  than  after  the  primary  healing 
of  incised  wounds. 


WOUND   REPAIR 


30 


Secondary  Wound  Healing.— Secondary  avouikI  healing,  character- 
ized by  the  devclupiiient  ol'  a  reddish,  ,t;i-anular  tissue  whieli  bleeds  easily, 
differs  from  primary  wound  healing.     It  depends  upon  the  same,  but 


^*^5^ 


-    "^Ivvcl 

\ 

1 

■     .9 

•    ^ 

^  ~»       t       ^ 

1    1^ 

.'/'    ■ 

'^  •i' 

,^-V''^      -              ■*' 

Fig.  36. — Section  from  a  Scar  in  the  Skin  Twenty-six  Days  Old.  (After  Marchand.) 
The  scar  (n)  con.sists  of  a  fibrillar  tissue  containing  numerous  oval  niielei  of  connective 
tis.sue  cells  and  newly  formed  blood  vessels;  (</)  the  connective  tissue  bundles  of  the 
cutis  are  intimately  interwoven  with  the  newly  formed  tissue.  Some  of  the  old  ela.-^tic 
fibers  pass  bej^ond  the  margins  of  the  .scar. 


considerably  exaggerated,  processes.  The  geniiinal  tissue — called  granu- 
lation tissue,  because  of  its  granular  appearance — lies  exposed  in  the 
wound,  fills  all  the  spaces  of  the  wound,  and  replaces  the  lost  tissues. 
This  granulation  tissue  develops  in  ;dl  wounds  in  which  pi-imai-y  wound 
healing  has  been  prevented  by  the  aeeunudation  of  blood  or  wound 
secretion  or  by  extensive  necrosis  of  the  tissues  following  trauma  or 
infection. 

Soon  after  the  injury  a  layer  of  fibrin  mixed  with  .some  blood  forms 
upon  the  surface  of  the  wound.  Within  two  days  this  fibrin  layer  ])e- 
C(mies  ((uite  firmly  attached  to  the  hypera'mic  swollen  tissues  of  the 
wound  and  transformed  into  a  yellowish,  cheesy,  fil)rino-purulent  mem- 
brane as  a  result  of  supei-ficial  necrosis  or  bacterial  inflammation  ac- 
companied by  the  accumulation  of  leucocytes.  The  secretions  discharged 
from  such  a  surface  may  present  all  the  transitional  forms  between  the 
serous  and  sero-purulent.  Earliest  after  three  days,  often  after  one 
week,  the  membrane  becomes  penetrated  at  different  points  by  small  red 


40 


WOUNDS,   THEIR  TREATMENT   AND   REPAIR 


granules,  each  granule  corresponding  to  a  small  blood  vessel  surrounded 
by  germinal  tissue.  Finally  the  necrotic  particles  are  separated  and  cast 
off  by  this  tissue,  and  the  entire  surface  of  the  wound  covered  by  it. 

Healing  of  granulating  surfaces  may  be  hastened  by  drawing  the 
edges  of  the  defect  together  with  adhesive  strips  or  inserting  tension  su- 
tures.   AVhere  the  granulating  surfaces  come  in  contact  they  will  unite. 


■•."-- "^ 


.-/ 


I'i 


Fig.  37. — Section  from  Wound  Four  Days  Old,  Following  Amputation  of  a  Dog's 
Tongue.  (After  Marchand.)  The  ends  of  the  divided  connective  tissue  bundles  (6)  ex- 
tend into  the  layer  composed  of  fibrinous  exudate  /;  within  and  beneath  the  fibrinous 
exudate  are  numerous  polynuclear  leucocytes;  gr,  small  vessel  which  becomes  continuous 
with  a  dilated  blood  space;  d,  small  artery  with  proliferating  wall;  c,  enlarged  fusiform, 
irregular  connective  tissue  cells. 

Granulfition  tissue  secretes  an  exudate  rich  in  cells  which  resembles 
pus.  This  exudate,  if  it  does  not  dry  and  form  a  crust,  cleanses  mechan- 
ically the  surface  of  the  wound,  and  has  a  bnctericidal  action  (cf.  Pyo- 
genic Infections,  Part  II,  p.  155).  It  is  especially  profuse  if  the  tissue  is 
infected. 

The  fibrillar  formed  by  the  fibroblasts  are  arranged  parallel  to  the 
surface  in  the  deeper  parts  of  the  Avound.  From  lu^re  they  pass  ver- 
tically along  willi  the  vessels  (Figs.  37  and  38)  into  the  upper,  but  less 
dense,  layers. 

The  covering  over  of  a  gi-anulating  surface  with  skin  proceeds  gradu- 
ally from  11i(!  margin  of  the  wound  in  the  form  of  a  bluish  border.     The 


WOUND    REPAIR 


41 


new  epithelium  grows  into  the  depths  between  the  vascular  loops  of  the 
granulations.  Small  islands  of  epithelium  also  develop  in  the  center  of 
the  granulating  surfaces  from  the  ducts  of  sweat  glands  and  from  hair 
follicles  which  were  not  totally  destroyed  by  the  injury  or  infection. 

Thick  connective  tissue  bundles  form  as  the  scar  develops.  By  the 
contraction  of  these  bundles  the  scar  is  reduced  in  size  and  neighboring 
structures  are  often  drawn  out  of  place,  causing  unsightly  deformities 
(ectropion  of  the  lids  and  lips).  Movements  of  the  fingers,  toes,  and 
larger  parts  of  the  extremities  may  be  interfered  with  (cicatricial  con- 
tractures). Elastic  fibers,  nerves,  and  the  appendages  of  the  skin  are 
not  found  in  the  scar. 

The  contracting  scar  becomes  extremely  pale  as  the  vessels  become 
obliterated.  The  surface  of  a  scar  is  smooth  and  white  and  remains  so. 
After  the  loss  of  a  large  amount  of  tissue  the  scar  may  be  depressed. 


r 


V 


Fio.  38. — Section  Through  the  Edge  of  a  Gkanulating  Incised  Wound  Adout  Three 
Weeks  Old  Surrounding  a  Fistul-e  Leading  to  an  steomyei.itic  Foci^s  in  the 
Femur.  (After  Marchand.)  c,  Cutis;  /,  fat;  e,  c',  newly  formed  cpidermi.s;  <jt,  granu- 
lations;  g,  vessels  of  the  granulations  ascending  from  the  cutis. 

nijpcrtrophic  Scar,  Cicatricial  Keloid. — If  the  connective  tissue 
continues  to  develop  and  does  not  contract,  large  tumor-like  masses  of 
cicatricial  tissue  supplied  with  large  blood  vessels  form  (hypertrophic 
scar,  cicatricial  keloid). 

Healing  Beneath  a  Scab. — Healing  beneath  a  scab  sometimes  re- 
sembles more  closely  primary,  at  other  times,  secondary  wound  healing. 
It  is  seen  most  often  in  non-jH^netrating,  superficial  wounds  of  the  skin 
(excoriations  of  the  skin,  dt^fects  following  removal  of  .strips  of  skin  for 
grafting).     The  blood  and  tissue  fluids  dry  to  form  a  firmly  attached 


42 


WOUNDS,    THEIR   TKEATMENT   AND    REPAIR 


crust,  or  become  united  with  the  dressings  to  form  a  protective  covering. 
Beneath  this  covering,  if  it  is  not  forcibly  removed,  and  if  inflammation 


Fio.  39. — Section  ok  Gkanilai  io.\    Ti.s.sli;  Kkmoviod  iiuni  an  Ahsckss  Membrane  Sur- 
rounding A  Sui'i'URATiNG  Focus  IN  BoNE.     Superficial  layer. 


does  iinj  occur,  new  cpillicliuiii  which  develops  from  the  edges  of  the 
wound  ;iri(l  lioiii  Ihc  dccpci-  layers  of  the  stratum  Malpighii,  in  the  same 
way  as  in  hiii-ns  of  llic  seitoiid  <k'gree,  is  foi-med  in  a  few  days. 


WOUND   REPAIR 


43 


In  deep  wounds  the  gro\\i;h  of  epithelium,  which  then  develops  only 
from  the  edges  of  the  wound,  may  go  on  to  completion  beneath  the  scab, 
which  in  a  fresh  wound  is  formed  by  the  wound  secretion  and  the  firmly 
adherent  gauze,  in  deep  contusion  of  the  skin  by  necrotic  tissue,  and 
after  cauterization  by  the  layer  of  tissue  which  has  been  destroyed. 
The  epithelium  extends  beneath,  the  scab  and  covers  the  wound,  if  the 
ch'nical  course  is  undisturbed,  before  granulation  tissue  develops  in  large 
amounts.  After  the  surface  is  covered  with  epithelium  the  crust  falls 
off  and  the  dry  gauze  which  may  have  been  applied  becomes  separated. 
c 


9 

Fig.  40. — Margin  of  \  Skix  Defect  Following  the  Removal  of  ICimdeh.mal  Sthits  for 
Skin  Grafting,  (.\fter  Marchand.)  a,  Newly  formed  ci)idermis  at  the  margins  of  tlie 
wound;  /,  end  of  the  same  which  projects  in  tlic  form  of  a  process  into  the  crust;  c,  which 
is  somewhat  loosened;  d,  space  in  which  iodoform  crystals  lie;  r,  cutis;  /,  which  is  almost 
unchanged;  jr,  a  newly  formed  epidermal  growth  which  has  exteiuled  downward  in  tiie 
form  of  a  round  process  between  the  connective  tissue  bundles. 

If  healing  beneath  the  scab  is  disturbed  by  removal  of  the  crust, 
or  dressings,  or  by  suppuration,  granulation  tis.sue  develops  in  rela- 
tively large  amounts  if  the  wound  has  not  already  become  covered  by 
epithelium. 

Occasionally  granulating  surfaces  may  be  covered  by  epithelium, 
M'hich  develops  under  the  scab  formed  by  the  desiccation  of  the  secretion 
discharged  from  them.  I^sually,  however,  such  scabs  retard  healing,  as 
they  prevent  the  discharge  of  wound  secretion. 


44  WOUNDS,   THEIR   TREATMENT   AND    REPAIR 

Macroscopic  Appearance  of  Granulation  Tissue. — Exposed  granula- 
tion tissue  varies  in  appearance  and  behavior,  depending  upon  whether  it 
is  healthy  or  diseased,  normal  or  pathological.  Healthy  granulation  tis- 
sue is  gi'anular,  firm,  deep  red  in  color,  bleeds  easily,  and  secretes  little. 
Diseased  granulation  tissue  is  pale,  soft,  spongy,  its  surface  smooth,  and 
the  granulations  are  covered  by  a  membrane. 

Causes  of  UnlicaltJnj  Granulation  Tissue. — The  cause  of  these  patho- 
logical changes  in  granulation  tissue  may  be  local  or  general.  In  anaemia, 
cachexia,  syphilis,  and  diabetes  the  organism  is  rarely  able  to  form  good, 
healthy  granulations.  They  are  pale  and  flabbj^  and  as  little  inclined 
to  form  connective  tissue  as  the  epithelium  is  to  cover  over  the  granu- 
lating surface.  The  local  causes  are  usually  infectious.  If  the  surface 
of  the  granulating  tissues  contains  microbes,  which  nniltiply  in  its  fibri- 
nous secretion,  or  is  continually  bathed  in  pus,  as  in  fistulous  tracts  or 
in  areas  adjacent  to  dead  tissues,  the  newly  formed  granulations  may 
grow  luxuriantly,  even  about  the  level  of  the  edges  of  the  skin  (proud 
flesh,  caro  luxurians).  If  this  is  the  case  connective  tissue  is  not  formed, 
as  the  fibroblasts  are  destroyed  by  the  bacterial  toxins  (Reinbach).  If  the 
membrane  containing  the  bacteria  is  removed  by  an  increased  exudation 
folloM'ing  the  artificial  irritation  (viz.,  quicksilver  salve,  silver  nitrate), 
or  the  deep  necrotic  tissue  (tendon,  piece  of  bone)  is  removed,  the  flabby, 
pale  granulations  will  become  transformed  into  healthy  granulations  and 
healing  will  occur.  Covering  over  of  unhealthy  granulations  with  skin 
is  impossible,  partly  because  of  the  luxuriant  growth  of  the  granula- 
tions above  the  edges  of  the  skin,  and  partly  because  of  the  secretion  of 
pus  from  the  infected  surface. 

Granulating  Wound  and  Ulcer. — The  granulating  wound  resulting 
from  an  injury,  a  burn,  or  cauterization  is  distinguished  from  the  granu- 
lating ulcer,  in  which  there  is  a  progressive  destruction  of  tissue.  The 
ulcer  heals  only  after  the  unhealthy  granulations  have  been  trans- 
formed into  the  healthy  (viz.,  tuberculous,  syphilitic,  ti^opho-neurotic 
ulcersj . 

The  Repair  of  Different  Tissues. — In  tissues  composed  of  connective 
tissues  and  specific  elements,  repair  by  granulation  tissue  or  scar  tissue 
is  the  most  important  method.  Regeneration  of  the  specific  cells  plays 
a  secondary  and  subordinate  role  (muscle,  nerve,  tendons,  large  viscera). 
In  some  cases  these  specific  elements  do  not  regenerate  at  all  (brain,  also 
apparently  spinal  cord,  vide  Part  IV).  Cartilage  and  bone  repair  by 
the  formation  of  germinal  tissue,  which  develops  from  the  perichon- 
drium and  periosteum,  the  germinal  tissue  reproducing  the  same  type 
of  tissue  as  that  destroyed  (callus).  The  union  of  two  serous  surfaces, 
which  are  approximated  in  intestinal  suturing,  'begins  with  agglutina- 
ti(in  by  a  layei-  of  (ihrin,  and  is  completed  by  the  formation  of  granula- 


WOUND   REPAIR  45 

tiou  tissue,  ■which  also  unites  the  rciiiainiiiu'  layers  (if  the  intestinal  wall. 
The  sear  upon  the  inner  surl'aee  of  the  intestinal  wall  is  covered  by  new 
epithelium  in  which  gland  tubules  form ;  there  is  Irtit  little  regeneration 
of  the  smooth  musculature.  AVherever  the  serosa  is  lost  or  destroyed  a 
layer  of  fibrin  forms  whicli  later  becom(>s  infiltrated  with  granulation 
tissue,  leading  to  the  formation  of  adhesions,  therefore  the  jXTitom-um 
in  all  abdominal  operations  must  be  spai-ed  as  nnich  as  possible  and 
protected  from  all  mechanical,  chemical,  and  i)hysical  (e.  g.,  desiccation) 
insults.  Similar  adhesions  may  be  caused  by  blood  clots,  which  become 
attached  to  the  peritoneum  or  hy  inflannuatory  exudates. 

Injured  and  ligated  arteries  are  repaired  by  the  formation  of  scar 
tissue.  The  proliferation  of  the  endothelium  and  connective  tissue  of 
the  vessel  wall,  with  the  formation  of  new  blood  vessels  which  develop 
from  the  vasa  vasorum  or  ad.jacent  blood  vessels,  precedes  scar  forma- 
tion. If  a  thrombus  develops  at  the  point  of  injury,  as  in  contusions  or 
lacerations  or  where  the  intima  is  roughened  (arterio-sclerosis)  repair 
will  be  delayed  by  organization  of  the  thrombus.  When  vessels  are 
ligated  under  aseptic  precaution,  a  thrombus  does  not  form  as  a  rule ;  if 
it  does  it  is  small.  The  connective  tissue  which  in  some  weeks  absorbs 
the  catgut  and  replaces  or  encapsulates  silk  ligatures,  c(mtributes  to  the 
firmness  of  the  scar,  which  usually  in  large  vessels  is  sufficiently  re- 
sistant in  about  three  weeks  to  withstand  the  blood  pressure  unassisted 
by  ligatures. 

Digestion,  Extrusion,  Encapsulation  of  Foreign  Bodies  hy  Granu- 
lation Tissue. — Granulation  tissue  also  plays  an  important  role  in  the 
digestion,  extrusion,  and  encai)sulation  of  foreign  bodies  and  necrotic 
tissue  and  in  the  healing  of  completely  separated  but  viable  tissues 
(transplantation) . 

These  essentially  different  processes  depend  upon  similar  tissue 
changes.  The  irritation  of  the  foreign  body  causes  a  reaction  which 
stimulates  the  growth  of  germinal  tissue.  Leucocytes  and  fibrobla.sts 
ingest  absorbable  and  dead  material,  and  produce  lacuna^  about  the 
periphery  of  a  foreign  body  which  are  comparable  to  the  lacuna'  pro- 
duced by  osteoclasts  in  the  absorption  of  bone.  Fibrin  and  catgut 
are  completely  absorbed  by  cellular  activity  and  replaced  l)y  prolifer- 
ating connective  tissue.  Necrotic  is  loosened  from  healthy  tissue  by  the 
same  process  and  surrounded  by  a  wall  of  connective  tissue,  an<l  is 
finally  completely  separated.  If  the  secretion  of  the  surrounding  granu- 
lation tissue  perforates  the  skin,  and  the  opening  is  favorably  situated, 
the  separated  dead  tissue  (necrotic  tendon,  sequestrum  of  bone)  will  be 
extruded.  It  is  the  same  with  penetrating  foreign  bodies  which  have 
carried  bacteria  into  the  wound.  The  rapidly  growing  connective  tissue 
surrounding  such  a  body  cannot  cicatrize,  but  maintains  a  profuse  puru- 


46  WOUNDS,   THEIR  TREATMENT  AND   REPAIR 

lent  secretion  which  prevents  healing  of  the  wound  and  liustens  the 
extrusion  of  the  foreign  body.  On  the  other  hand,  foreign  bodies  which 
irritate  the  tissue  bift  little,  and  contain  only  bacteria  which  are  readily 
destroyed  by  the  tissue,  are  completely  encapsulated  and  the  wound 
heals.  Such  foreign  bodies  become  imbedded  in  a  connective  tissue  cap- 
sule. The  encapsulation  of  bullets,  pieces  of  steel,  and  especially  of 
suture  material  (silk,  silver,  aluminum  bronze  wire)  is  a  very  impor- 
tant process  from  a  surgical  viewpoint.  Buried  silk  sutures  become  com- 
pletely infiltrated  Avith  germinal  tissue  and  can  be  used  to  bridge  over 
defects  in  the  repair  of  tendons,  the  germinal  tissue  developing  between 
the  sutures  and  bridging  over  the  defect. 

Virulent  bacteria  may  be  encapsulated  with  foreign  bodies,  from 
which  deep  inflammatory  processes  may  develop  years  later  if  the  sur- 
rounding connective  tissue  capsule  is  ruptured  by  trauma.  Frequently 
pieces  of  clothing  which  have  been  carried  into  the  tissues  with  bullets 
become  encapsulated. 

Skin  Grafting. — Skin  grafting  is  employed  to  promote  the  rapid 
healing  of  large  fresh  wounds  and  granulating  surfaces  of  different  sizes. 
A  number  of  different  methods  liave  been  devised,  but  only  those  will  be 
mentioned  which  have  been  tested  and  found  to  be  satisfactory.  In  the 
method  devised  by  Reverdin  and  Thiersch  small  pieces  or  long  strips 
of  epidermis  including  the  stratum  papillare  are  used,  while  in  the 
metliod  emplo.yed  by  von  Esmarch,  Krause,  and  others  the  entire  cutis 
(cutis  strips)  with  or  without  a  layer  of  fat  is  employed.  The  raw  sur- 
faces of  the  grafts  are  applied  to  the  granulating  or  vivified  wound 
surfaces. 

Mctliod  of  Repair. — As  in  primary  wound  healing,  agglutination  by 
a  thin  hiyer  of  fibi'iii  is  the  first  step  in  tlie  process  of  healing  of  skin 
grafts  unless  })reveiited  by  haemorrhage  or  infection.  This  fibrin  layer 
is  soon  infiltrated  by  leucocytes,  fibroblasts,  and  newly  formed  vessels 
develoj)ing  from  the  Mouiid  surfaces.  Circulation  is  reestablished  in  the 
grafts  in  a  .short  time.  Endei-len  has  successfully  injected  these  newly 
formed  vessels  and  traced  them  into  the  papillary  layer.  lie  has  demon- 
strated their  jiresence  in  epidermal  grafts  as  early  as  the  second  day; 
in  cutis  grafts  as  eai-ly  as  tlie  third  day.  In  the  epidermal  grafts  only  the 
superficial  (■i)itheliuni  dies;  the  deeper  layers  proliferating  actively  as 
(■arly  as  the  sccoiid  (l;iy.  Tlie  entii'c  epidermis  is  cast  off'  from  cutis 
giiifls,  l)ut  is  replaced  by  the  proliferation  of  islands  of  epithelium 
remaining  in  tlie  deeper  layers  of  the  epithelium,  of  the  sweat  glands  and 
of  the  edges  of  the  wound. 

Kpidei-mal  grafts  heal  in  position  more  rapidly  than  cutis  grafts. 
When  the  former  are  used,  repair  is  definitely  established  in  from  one 
to  two  we<'l<s.   while  the  latter   re((uire   from  thi'ee  to  five   weeks.     W. 


WOUND   REPAIR  47 

Braim  states  that  the  fibrous  and  elastic  elements  of  the  grafts  are  re- 
tained. His  findings  are  the  opposite  of  those  of  Enderlen,  and  he  be- 
lieves that  this  is  due  to  the  fact  that  ho  had  more  favorable  material  for 
examination. 

nistological  Cliaugcs  in  tlie  Grafts. — According  to  the  histological 
investigations  of  Enderlen,  the  fibrous  and  elastic  tissues  of  the  cutis 
grafts  gradually  degenerate  and  are  replaced  by  newly  formed  tissue, 
Miiich  develops  in  part  from  the  connective  tissue  elements  of  the  graft. 
The  cells  of  the  ducts  of  sweat  glands  and  hair  follicles  also  regenerate 
to  replace  those  lost  during  the  first  few  days. 

Sensation  is  restored  in  the  graft  in  al)out  six  weeks,  extending  from 
the  periphery  toward  its  center. 

The  changes  occurring  in  the  pigment  of  the  skin  are  interesting 
and  remarkable.  If  skin  is  transplanted  from  a  negro  to  a  white  man, 
the  pigment  gradually  disappears  and  the  graft  becomes  white,  while 
if  the  graft  is  taken  from  a  white  man  and  placed  upon  a  negro,  it 
gradually  becomes  pigmented. 

Early  Appearance  of  the  Grafted  Area. — The  grafted  area  appears 
bluish  red  in  color  and  slightly  depressed  at  first.  Gradually  the  color 
becomes  paler,  and  as  contraction  occurs  a  smooth  scar,  covering  the 
site  of  the  former  defect,  develops;  sometimes,  however,  disfiguring 
keloid-like  masses  develop  upon  the  surface.  The  wound  resulting  from 
the  removal  of  the  grafts  heals  in  from  one  to  two  weeks  under  a  dry 
dressing  (healing  beneath  a  scab),  and  after  this  time  grafts  may  again 
be  taken  from  the  same  area,  which  remains  of  a  reddish  color  for  some 
time  and  later  becomes  pigmented. 

Transplanted  cutis  strips  contract  but  little,  Avhen  the  process  of 
healing  is  undisturbed;  contracting  the  least  when  they  contain  a  thin 
layer  of  fat.  In  about  five  weeks  they  resemble  closely  the  surrounding 
skin,  are  movable,  and  are  easily  displaced  over  the  subjacent  tissue 
{vide  Plastic  Operations).  The  healing  of  secondary  defects  may  be 
hastened  by  suture  and  the  grafting  of  epidermal  strips. 

Transplantation  of  Mucous  Membrane. — The  transplantation  of  nui- 
cous  membrane  was  successfully  attempted  by  Czerny  in  1871.  It  has 
been  used  particularly  by  Wolfler,  UhthofP,  and  others  to  repair  con- 
junctival defects  and  replace  eyelids ;  the  nnicous  membrane  being  taken 
preferably  from  the  lips  or  cheeks.  If  the  epithelium  of  the  grafts  des- 
quamates, it  is  rapidly  regenerated. 

Transplantation  of  Cartilage  and  Bone. — Cartilage  may  be  success- 
fully transplanted  if  the  perichondrium  is  attached.  Kredel  used  a 
piece  of  the  auricular  cartilage  to  support  the  ahe  nasi;  von  IMangoldt 
introduced  subcutaneously  a  costal  cartilage  to  raise  a  sunken  nasal 
bridge;  Fritz  Koenig  used  with  excellent  results  a  cuneiform  piece  of 


48 


WOUNDS,   THEIR  TREATMENT   AND   REPAIR 


the  pinna  to  replace  the  als  nasi.     If  the  perichondrium  is  not  trans- 
planted the  cartilage  is  gradually  absorbed  (Marchand). 

The  transplantation  of  bone  to  overcome  a  bony  defect  is  of  great 
surgical  importance.  Attempts  had  been  made  at  the  beginning  of 
the  last  century  to  close  trephine  openings,  by  replacing  the  button  of 
bone  removed.  The  experimental  and  practical  work  of  Oilier  has 
extended  the  usefulness  of  bone  transplantation  in  a  number  of  different 
ways. 


A:-.. 


nk 

Fig.  41. — Bone  Formation  at  the  Margin  op  a  Medullary  Cavity  and  About  the  Ha- 
versian Canals  (Freshly  Transplanted  Bone  as  It  Appears  Microscopically 
After  Forty-nine  Days).  (Aftor  Marchand.)  o,  Osteoblasts;  k,  newly  formed  bone; 
nk,  bone  which  has  become  necrotic;  g,  an  injected  blood  vcs.sel. 


It  makes  little  difference  whether  the  bone 
without  periosteum  and  medulla,  whether  it  is 
from  another  person,  or  from  a  lower  animal, 
dead  (and  in  the  latter  case  sterilized  by  boil 
differs  in  this  respect  from  all  other  tissues.  V>\\ 
tlie  ff)ll()\viiig  explanation  of  this  difference:  Tr; 
completely  preserved,  being  for  the  most  part 
by  newly  formed  bone.    The  salts  of  bone  play 


is  transplanted  with  or 
taken  from  the  patient, 

whether  it  is  living  or 
ing  or  flaming).  Bone 
rth  and  Marchand  offer 
msplanted  bone  is  never 

absorbed  and  replaced 
an  important  role  in  its 


WOUND   REPAIR  49 

regeneration,  for  while  (leealeifuMl  bone  is  quickly  absorbed,  tlic  bone 
ash  stinuilates  the  encapsulating  connective  tissue  to  form  thin  lamclhe 
of  bone  (Barth).  Pieces  of  bone  with  i)eri()steuni  attaciied,  which  are 
taken  from  the  same  person  and  immediately  transplanted,  oifer  con- 
ditions most  favorable  for  encapsulation. 

In  the  process  of  encapsulation  a  layer  of  fibrin  is  formed  first  which 
later  becomes  infiltrated  by  newly  formed  connective  tissue.  The  nuclei 
of  the  bone  corpuscles  and  marrow  cells  degenerate  and  they  die,  only 
the  most  superficial  layers  of  cells  in  the  transplanted  bone  being  pre- 
served, unless  injured  during  transplantation.  As  early  as  the  fifth  day 
young  connective  tissue  cells,  developing  from  the  adjacent  actively  pro- 
liferating connective  tissue,  and  young  blood  vessels  grow  into  the  medul- 
lary spaces  and  Haversian  canals.  On  the  eighth  day,  as  a  rule,  the 
entire  piece  of  transplanted  bone  is  surrounded  and  infiltrated  by  con- 
nective tissue,  the  replacement  of  the  dead  medullary  tissue  in  the  inte- 
rior of  the  transplanted  bone  requiring  a  longer  time. 

[The  transplanted  bone  is  gradually  absorbed,  being  replaced  by 
granulation  tissue  which,  eventually  forms  new  bone.  The  transplanted 
bone  then  acts  merely  as  a  scaffolding  or  framework  for  the  rapidly  pro- 
liferating bone  tissue.  These  newly  formed  cells  infiltrate  the  Haversian 
canals  and  the  bone  marrow  and  aid  in  the  absorption  of  the  trans- 
planted tissue.  Giant  cells  are  also  found,  especially  upon  the  surface 
of  the  transplanted  bone,  which  correspond  to  the  osteoclasts  found  in 
normal  bone  formation.  These  giant  cells  also  perform  apparently  the 
same  function  in  transplanted  as  in  developing  bone,  digesting  the  bone 
and  aiding  in  its  removal.  The  giant  cells  usually  lie  in  deep  depres- 
sions upon  the  surface,  which  correspond  to  Howship's  lacuntv.  The 
more  rapidly  this  granulation  tissue  forms,  the  more  rapidly  the  layers 
of  bone  containing  degenerated  nuclei  are  destroyed  and  replaced.  The 
space  between  the  transplanted  bone  and  the  edges  of  the  bone  is  soon 
filled  with  this  tissue.] 

The  time  required  for  absorption  and  replacement  usually  depends 
upon  the  thickness  of  the  piece  of  bone  transplanted,  being  most  rapid 
Avhen  fresh  material  is  used.  If  some  of  the  periosteum  about  the  bony  de- 
fect is  raised  and  laid  over  th^  transplanttMl  bone,  rcjiair  will  be  hastened. 

The  Use  of  Ivory  Pegs  to  Fix  Fragments  of  Bone. — Ivory,  which  is 
used  mostly  in  the  form  of  pegs  to  unite  fractures,  is  acted  upon  in  nuich 
the  same  w^ay  as  dead  bone  tissue.  The  surface  of  the  ivniy  peg  is 
gradually  worn  away  and  the  small  depressions  are  filled  with  newly 
formed  granulations,  which  are  firmly  united  with  the  surrounding  tissue, 
and  the  peg  is  eventually  encapsulated  if  sterile. 

Transplantation  of  Muscles  and  Nerves. — Strictly  speaking,  muscles 
and  nerves  are  not  used  for  transplantation.     If  separated  from  their 


50  WOUNDS,   THEIR  TREATMENT   AND   REPAIR 

connections  they  degenerate  completelj^  even  if  healing  occurs.  By 
muscle,  tendon,  and  nerve  transplantations  are  understood  operations  in 
which  functioning,  living  structures  are  united  with  diseased,  nonfunc- 
tioning structures;  the  connections  of  the  living  tissue,  however,  never 
being  completely  divided  (cf.  Injuries  and  Diseases  of  Soft  Tissues). 

Czerny  used  successfully  a  lipoma  to  replace  a  breast  which  he  had 
amputated  for  an  adeno-fibroma  and  hypertrophy. 

The  transplantation  of  parts  of  blood  vessels  has  been  successfully 
performed  by  Iloepfner  and  Carrel  and  Guthrie  in  animals.  Hoepfner 
used  the  technic  advised  by  Payr  in  making  the  arterial  anastomoses 
(cf.  Injuries  of  Arteries).  The  defect  in  the  artery  was  replaced  by  a 
piece  of  an  artery  from  the  same  animal  or  another  of  the  same  species. 

The  transplantation  of  parts  of  organs  is  of  practical  importance. 
Thj^roid  gland  tissue  has  been  transplanted  in  cases  of  myxoedema  fol- 
lowing operations,  and  although  encapsulation  with  regeneration  is  pos- 
sible, the  results  are  not  satisfactory.  Feeding  of  thyroid  preparations 
is  more  simple  and  just  as  effective. 

The  Use  of  Foreign  Inorganic  Materials. — Foreign  inorganic  mate- 
rials (alloplasty)  have  been  used  for  some  time  to  close  defects  in  bone, 
particularly  in  the  skull,  to  raise  the  sunken  nasal  bridge  in  saddle- 
nose,  or  to  close  large  hernial  rings.  Plates  of  amber,  platinum,  cellu- 
loid, ivory,  gold  foil,  and  silver  wire  filigree  are  inferior  to  living  bone 
for  purposes  of  transplantation.  These  foreign  bodies  will  become  en- 
capsulated if  they  have  been  previously  thoroughly  sterilized,  and  if  the 
operation  is  performed  aseptically.  If,  however,  they  produce  pressure 
upon  or  rub  against  the  skin,  fistulte  w'ill  form.  Liquid  or  solid  par- 
affin has  been  used  to  raise  the  skin  in  saddle-nose,  to  reinforce  a  poorly 
functioning  sphincter  ani,  to  make  an  artificial  testicle,  etc.  (Gersuny, 
Eckstein,  Stein). 

Literature. — W.  Braun.  Klin.-histol.  Untersuchvingen  iiber  die  Anheilimg 
ungestielter  Huutlappen.  Beitr.  z.  klin.  Chir.,  Bd.  25,  1899,  p.  211. — Brunner.  Wund- 
infektion  u.  Wuiidhehundlung  II,  Frauenfeld,  1898. — Eckstein.  Hartparaffinprothesen. 
Borl.  klin.  Wochenschr.,  1902,  p.  ;U5. — Kredel.  Die  angeborenen  Nasenspalten  und 
ihre  Operation.  Deutsche  Zeitschrift  fvir  Chirurgie,  Bd.  47,  1898,  p.  237. — v.  Mangoldt. 
Die  Einpfianzung  v.  Rippenknorpel,  etc.  Chir.-Kongr.  Verhandl.,  1900,  II,  p.  460. — 
Marchnnd.  Der  Prozess  der  Wundheihing.  Deutsche  Chir.,  1901. — Pmjr.  Implanta- 
tion der  Schilddriise  in  die  Milz.  Chir.-Kongr.  Verhandl.,  1906. — Reinbach.  Unter- 
suchungen  nicnschlichcr  Granulationen.  Zieglers  Beitr.  z.  pathol.  Anatomie,  Bd.  30, 
1901,  p.  102. — Ribhert.  Uober  Traiusi)lantation  auf  Individuen  anderer  Gattung. 
Verhandl.  d.  Deutsch.  Pathol.  Oesellscli.  Zentrall)!.  f.  allg.  Pathol.,  Bd.  l.j,  1905.  Ergan- 
zungshcift,  ]).  104. — Riggenhach.  Ueber  den  Keimgehalt  accident.  Wunden.  Deutsche  I 
Zeits(;hr.  f.  Cliir.,  Bd.  47,  1898,  p.  S^i.—Schloffer.  Ueber  Wiuidsekrete  und  Bakterien 
bei  der  Ileilung  per  priinani.  Arch.  f.  klin.  Chir.,  Bd.  57,  1898,  p.  322.— ^S^ein.  Parafiin-j 
Injc;ktionen,  Theorie  u.  Praxis,  Stuttgart.     Enke,  1904. 


II.    ASEPTIC   TECHNIC 

All  the  methods  employed  in  the  treatment  of  wounds,  before  the 
nature  and  causes  of  wound  infections  Avere  recognized,  were  unsuccess- 
ful. AVhat  were  ill-directed  attempts  to  determine  the  cause  of  and 
prevent  wound  infections,  became  definite  and  direct  with  Pasteur's  dis- 
covery (1861)  that  fermentation  and  putrefaction  of  organic  masses 
Mere  caused  by  ferments  of  a  vegetable  or  animal  nature.  Lister's  sug- 
gestion (1867)  that  wound  infections  must  have  a  similar  cause  has 
been  most  fruitful  for  the  entire  field  of  surgery,  and  remains  to-day 
the  most  important  milestone  in  its  history. 

The  result  of  Lister's  work  was  that  an  attempt  was  made  to  sterilize 
everything  coming  in  contact  wdth  the  w^ound,  even  the  air.  Lister  used 
carbolic  acid  for  this  purpose,  after  it  had  been  demonstrated  that  it 
would  destroy  the  odor  of  sewerage  and  the  intestinal  worms  which  in- 
jured grazing  cattle.  It  had,  however,  been  used  independently  by  an 
Italian  surgeon  since  1868.  In  the  method  as  originally  devised  by 
Lister  the  skin,  hands,  instruments,  sponges,  sutures,  and  ligatures  were 
sterilized  with  a  five  per  cent  solution  of  carbolic  acid,  and  a  spray  of  a 
two  and  a  half  per  cent  solution  of  carbolic  acid  was  kept  playing  dur- 
ing the  operation  to  prevent  air  infection,  w'hich  was  particularly  feared. 

The  temporary  and  permanent  dressings  were  also  saturated  with  a 
solution  of  this  acid.  Lister's  experiment  w'as  a  success,  and  with  one 
blow  operative  surgery  was  rid  of  its  woi-st  enemies — hospital  gangrene 
aud  the  severe  and  fyeeiuenthj  fatal  putrefactive  and  pyogenic  in- 
fections. 

In  the  antiseptic  method  of  w^ound  treatment,  originally  introduced 
by  Lister,  an  attempt  was  made  to  prevent  the  development  of  wound 
infections  and  to  combat  those  already  developed  by  the  use  of  dilferent 
antiseptics.  The  year  1886  marks  the  beginning  of  the  aseptic  method  of 
wound  treatment,  special  emphasis  being  laid  iipon  the  preventi<m  of 
wound  infections,  mechanical  and  physical  methods  of  sterilization  being 
chiefly  relied  upon.  As  in  any  innovation,  a  number  of  different  com- 
plicated aseptic  methods  and  procedures  were  introduced.  Later  inves- 
tigations have  shown  that  many  of  these  are  superfluous,  and  have  com- 
pelled a  return  to  simpler  but  as  effective  methods. 

5  51 


52  ASEPTIC  TECHNIC 

The  science  of  bacteriology,  which  began  with  Koch's  discovery  of 
the  anthrax  bacilhis  (1876)  and  the  introduction  of  solid  culture  media, 
required  for  making  pure  cultures  of  bacteria  (1881),  and  was  placed 
upon  a  firm  basis  by  Rosenbach  (1884),  has  shown  how  extensively  the 
pathogenic  bacteria  are  distributed.  It  is  little  wonder,  after  the 
brilliant  confirmation  of  Pasteur's  germ  theory  and  the  justification 
of  Lister's  suggestion  that  wound  infections  were  caused  by  bacteria, 
that  the  latter 's  method  as  originally  employed  or  modified  by  him 
was  extensively  used.  In  the  early  period  of  antisepsis  the  operating 
room  resembled  a  carbolic  acid  bath.  The  carbolic  acid  spray  was 
soon  discarded  in  order  to  prevent  infection  through  the  air  cur- 
rents produced  by  its  use.  It  was  soon  demonstrated,  however,  that 
the  dangers  of  air  infection  were  much  less  than  those  of  contact  infec- 
tion through  the  hands,  instruments,  and  dressings,  and  although  the 
spray  was  discarded,  antiseptic  solutions,  sometimes  carbolic  acid,  at 
other  times  sublimate  solution,  which  is  active  in  much  weaker  solution, 
w'ere  still  permitted  to  run  over  the  w^ound  during  the  course  of  the 
operation,  the  use  of  these  antiseptics  during  the  operation  being  con- 
sidered very  essential. 

Later  improved  methods  of  investigation  (Geppert)  demonstrated  that 
the  bactericidal  action  of  the  antiseptic  solutions  in  wounds  and  upon 
the  surface  of  the  body  had  been  greatly  overestimated.  It  was  shown 
that  antiseptics  did  not  reach  bacteria  lying  in  the  superficial  epithelium 
and  attached  to  foreign  bodies ;  that  they  were  inactive  in  wounds  form- 
ing chemical  union  with  the  albuminous  secretions ;  and  that  they  de- 
stroyed the  superficial  bacteria  only  after  long  contact,  injuring  at  the 
same  time  the  tissues  and  viscera,  thus  reducing  the  natural  resistance 
of  the  organism.  In  addition  it  was  demonstrated  that  the  antiseptic 
dressings,  because  of  the  volatility  of  the  agents  employed,  had  no 
marked  bactericidal  powers  and  even  harbored  bacteria  (Schlange)  ; 
that  operation  wounds  treated  with  antiseptic  solutions  secreted  more 
profusely  and  healed  more  slowly  than  those  treated  by  the  dry  method 
(Landei'er,  von  Bergmanu),  and  that  irrigation  of  severely  inflamed 
tissues  favored  the  extension  of  the  infection  (von  Bergmann). 

Guided  by  the  results  of  bacteriological  investigations  of  Koch, 
(Jal'fky,  and  Liilfler  (1881),  surgeons  tni-ned  to  physical  methods,  of 
which  stei'ili/.ation  by  live  steam  and  boiling  water,  excepting,  of  course, 
meclianicfd  cleansing,  ai-e  the  most  impoi-tant.  The  entire  procedure,  to 
the  perfection  of  which  von  Pjergmann,  von  Esmai-ch,  Landerer,  Neuber, 
and  Schimmelbusch  have  contributed  most,  is  known  as  asepsis,  and  has 
replaced  cbemical  sterilization  by  the  use  of  antiseptics.  Even  at  the 
present  time  antiseptics  are  indicated  and  required  in  certain  cases,  but 
they  no  longer  as  formerly  are  depended  upon  alone,  being  merely  inci- 


PREPARATION  OF  THE  SURFACE  OF  THE  BODY        53 

dental  as  contributing  to  the  success  of  aseptic  technic.  It  would  be 
more  correct  to  speak  of  physical  and  chemical  antisepsis. 

It  would  be  impossible  in  a  book  of  this  character  to  discuss  at  length 
the  different  features  of  aseptic  technic  as  employed  by  different  sur- 
geons, and  besides  it  Avould  be  tiresome  and  confusing  to  the  reader. 
Each  method  differs  as  to  detail,  but  there  is  a  general  principle  which 
is  common  to  all.  In  the  following  chapters  a  simple  but  effective  aseptic 
technic  will  be  described.  It  can  be  easily  followed  by  physicians  and 
surgeons,  who  are  often  required  to  operate  in  private  homes  and  do 
not  have  access  to  the  conveniences  of  a  hospital. 

[A  number  of  surgeons  regard  the  use  of  head  i)ieces,  covering  the 
hair  and  protecting  the  mouth  and  nose,  as  superfluous.  Clinical  expe- 
rience, however,  seems  to  indicate  that  the  best  results  are  obtained  when 
the  mouth  and  nose  are  covered  either  with  a  special  mask  or  with  sterile 
gauze  and  the  head  is  covered  with  gauze  or  a  cap.  Rubber  gloves  are 
being  very  extensively  used,  being  the  best  safeguard  against  infection 
of  the  patient,  and  at  the  same  time  protecting  and  preserving  in  good 
order  the  surgeon's  hands.  Rubber  gloves  can  easily  be  prepared  for 
any  operation  in  private  practice,  and  special  masks  for  the  head  and 
face  may  be  so  easily  procured  or  made  when  needed  that  they  should 
be  used  in  every  case.] 


CHAPTER    I 

PREPARATION  OF  THE  SURFACE  OF  THE  BODY 

The  skin  is  the  habitat  of  numerous  varieties  of  bacteria,  among 
which  the  ordinary  p^^ogenic  and  putrefactive  bacteria  arc  most  com- 
monly found.  The  removal  of  these  bacteria  from  the  skin  of  the  hands 
and  the  field  of  operation  is  a  most  difficult  task,  but  one  that  is  indis- 
pensable to  successful  results  in  surgery.  The  bacteria  are  hidden  not 
only  in  the  fat  covering  the  skin,  but  also  in  the  superficial  layers  of  the 
epidermis,  in  the  outer  parts  of  the  hair  follicles,  in  the  ducts  of  the 
sweat  glands,  and  even  in  the  most  insignificant  wounds  and  fissures 
of  the  epidermis.  Haegler,  after  rubbing  a  culture  of  bacteria  upon 
the  skin,  could  demonstrate  bacteria  at  all  the  points  above  mentioned, 
and  they  can  be  demonstrated  in  normal  skin. 

Sterilization  of  the  Hands. — The  results  of  the  investigations  of  von 
IMikuliez,  Haegler,  Paul  and  Snrwey,  Gottstein,  and  othcr.s  have  shown 
that  it  is  impossible  to  completely  sterilize  the  hands  in  a  bacteriological 
sense  for  an  entire  operation.     The  surgeon  and  his  assistants  should 


54 


ASEPTIC   TECHNIC 


attempt  to  approach  the  ideal  as  closely  as  possible,  and  even  when 
sterilization  has  been  as  thorough  as  possible,  should  regard  the  hands 
as  very  unreliable  and  exercise  due  precaution  to  prevent  infections. 
The  difficulties  of  hand  sterilization  may  be  easily  recognized  if  the  skin 
is  examined  under  the  lens,  when  all  the  fissures,  which  resemble  the 
furrows  in  a  newly  plowed  field,  may  be  recognized,  and  one  remembers 
that  all  the  roughened  areas,  still  more  the  small  wounds  and  fissures, 
afford  the  best  resting  place  for  bacteria. 

Of  the  different  methods  of  hand  sterilization  which  have  been  intro- 
duced, that  of  Fiirbringer  is  the  most  extensively  used,  and  is  to  be 
recommended.  It  is  practiced  in  the  von  Bergmann  clinic  at  the  present 
time  in  the  following  way : 

1.  IMechanical  cleansing  of  the  hands  and  forearm  for  ten  minutes 
in  hot  water  with  soap  and  brush ;  of  the  space  beneath  the  free  margin 
of  the  nail  and  nail  folds  wdth  a  nail  file  or  cleaner. 

2.  Thorough  drying  of  the  hands  and  forearm  with  a  sterile  towel. 

3.  AVashing  for  three  minutes  in  from  seventy  to  eighty  per  cent 
alcohol. 

4.  Washing  for  three  minutes  in  1  to  2,000  sublimate  solution. 

The  first  act  is  the  most  important.  The  hot  water  and  soap  and 
the  vigorous  rubbing  with  the  brush  remove  the  fats  covering  the  skin, 
and  loosen  and  separate  the  upper  cornified  layers  of  the  epidermis. 

[In  the  Bevan  clinic  the  same  methods  are  employed  with  two  excep- 
tions: (1)  The  bichloride  has  been  entirely  dispensed  with,  and  (2)  rub- 
ber  gloves   are   invariably   worn 
by   the   surgeon,    assistants,    and 
nurses.] 

Simple  bristle  hand  brushes 
are  most  valuable,  and  cannot  be 
replaced  by  any  other  agent. 
Before  using,  a  large  number 
should  be  sterilized  in  a  lead  can 
or  linen  bag.  In  private  prac- 
tice it  is  recommended  that 
the  brushes  be  boiled  in  water 
and  then  k(>])t  in  a  1  to  5,000 
bichloride  solution.  The 
brushes  should  be  freed  of  all 
srap  befoi-e  being  placed  in  the 
solution,  as  soap  forms  a  chemi- 
cal compound  with  mercury, 
A\lii('li  is  inactive.  Five  l)rnsb('s  will  do  very  well  for  minor  operations, 
and  ten  usually  suffice  for  major  ones. 


Fia.  42. — Lead  Box  with  Tiiays  for  Brushes 
FOR  Sterilization  in  Steam. 


PREPARATION  OF  THE  SURFACE  OF  THE  BODY       55 

After  washing-,  each  brush  coiitains  iiiiiiicioiis  bacteria,  especially  in 
its  deeper  parts.  AVhile  the  danger  of  transferring  bacteria  while  wash- 
ing nnder  flowing  water  is  probably  not  great,  it  has  become  a  rule  that 
a  brush  once  used  should  not  be  used  again  until  it  has  been  sterilized. 
A  number  of  brushes  should  be  used  in  sterilizing  hands  to  which  grosser 
particles  of  dirt  are  attached,  or  which  have  been  in  contact  with  pus 
or  fiBces. 

The  dangerous  space  beneath  the  free  margin  of  the  nails  and  the 
nail  folds  demand  especial  attention.  The  grosser  particles  of  dirt 
should  be  removed  with  a  nail  cleaner  before  washing  is  begun.  Cleans- 
ing of  the  nails  should  be  continued  during  the  process  of  washing,  as 
the  finer  particles  to  which  the  bacteria  are  attached  become  separated 
and  may  be  removed  with  soap  and  brush.  If  the  free  margin  of  the 
nail  is  not  longer  than  two  millimeters,  the  space  beneath  can  be  cleaned 
very  satisfactorily  with  the  brush,  as  the  bristles  penetrate  into  all  the 
depressions  and  recesses.  The  brush  is  far  superior  for  this  purpose 
to  a  number  of  substitutes  such  as  orange-wood  sticks,  pumice  stone,  sand, 
different  soap  mixtures,  etc.,  which  have  been  introduced.  Trinnning 
the  nails  short  has  been  recommended  by  some  surgeons.  It  should  be  dis- 
couraged, however,  as  the  space  between  the  nail  and  the  skin  is  then  ex- 
posed, becomes  rough  and  fissured,  rendering  sterilization  more  difficult. 

Mechanical  sterilization  of  the  hands  is  an  art  to  be  acquired  by 
practice,  depending  less  upon  the  time  actually  spent  in  the  process  than 
upon  the  way  and  thoroughness  with  which  the  surface  of  the  hands 
and  forearm  are  washed  and  scrubbed.  Haegler  has  recommended  a 
method  by  which  the  thoroughness  of  the  sterilization  may  be  tested. 
After  the  fats  are  removed  by  washing,  and  the  hands  and  forearms 
have  been  thoroughly  dried,  a  few  drops  of  licjuid  Chinese  dye  are  rubbed 
into  the  skin.  The  surfaces  are  then  scrubbed  as  usual  with  soap,  water, 
and  brush,  and  then  examined  with  a  lens.  All  the  areas  which  have 
been  neglected  may  be  easily  seen,  as  they  will  still  be  stained.  One 
soon  learns  by  these  attempts  how  to  wash  his  liantls  thoroughly.  Special 
attention  should  always  be  paid  to  the  space  beneath  the  free  margin 
of  the  nails,  the  deep  furrows  in  the  palm  of  the  hand,  the  interdigital 
spaces,  and  the  outer  side  of  the  forearm. 

The  water  should  be  used  as  hot  as  possibl(>.  In  all  large  institu- 
tions provided  Avith  running  water  the  hot  Avater  may  be  regarded  as 
germ  free,  in  spite  of  the  fact  that  it  contains  a  number  of  harmless 
varieties  of  micro-organisms.  AVhere  there  is  no  running  water  it  may 
be  boiled  in  kettles;  after  boiling  for  five  minutes,  it  may  be  regarded  as 
germ  free. 

The  arrangements  for  washing  vary.  In  clinical  institutions  and 
hospitals  the  bowls  should  be  so  constructed  -that  they  may  be  easily 


56  ASEPTIC   TECHNIC 

cleaned,  and  that  the  water  wliieh  is  discharged  from  a  tap  may  be; 
turned  on  or  off,  and  that  the  amount  of  hot  and  cold  water  may  be 
regulated  by  the  foot  or  forearm.  [It  is  preferable  that  the  stopcock 
be  so  arranged  that  the  flow  of  water  can  be  controlled  by  foot  pres- 
sure. This  is  much  more  convenient,  and  there  is  much  less  danger  of 
soiling  the  hands  and  forearm  in  an  endeavor  to  turn  the  water  off  or 
to  regulate  the  amount  of  hot  and  cold  water  discharged.] 

In  the  simplest  arrangement  an  attendant  manipulates  the  stopcock, 
renewing  the  water  when  necessary,  and  regulating  the  amounts  of 
hot  and  cold.  In  private  practice  an  ordinary  wash  bowl  which  has 
previously  been  thoroughly  cleaned  with  hot  water  may  be  used.  In 
this  case  the  water  must  be  changed  at  least  three  times  before  the  hands 
can  be  regarded  as  thoroughly  sterilized. 

All  soaps  used  by  the  surgeon  should  be  alkaline,  as  these  favor  the 
separation  of  the  superficial  layers  of  the  epidermis.  The  tincture  of 
green  soap  and  soft  soap  are  very  extensively  employed. 

If  in  private  practice  one  is  compelled  to  use  toilet  soaps,  mechanical 
sterilization  nmst  be  more  vigorous,  in  order  to  make  up  for  the  deficien- 
cies of  the  soaps,  which  usually  are  fatty  and  neutral  and  do  not 
favor  the  separation  of  the  superficial  layers  of  the  epidermis. 

After  the  hands  and  forearms  have  been  washed  and  scrubbed  thor- 
oughly for  the  required  length  of  time,  they  should  be  dried  with  a 
sterile  hand  towel.  In  this  way  the  epidermis  which  has  become  loos- 
ened as  a  result  of  the  washing  is  removed.  The  towel  should  not  be  used 
again  until  sterilized,  as  it  takes  up  numerous  bacteria. 

Was]ii)uj  ivitli  Alcoltol. — AVashing  with  alcohol  is  a  very  important 
step  in  the  procedure.  When  rubbed  into  the  skin  with  sterile  gauze 
or  a  brush  it  penetrates  the  deepest  furrows,  removing  the  fat  and 
dehydrating  the  superficial  layers  of  the  epithelium,  and  prepares  the 
skin  for  the  action  of  the  aqueous  solution  of  the  antiseptic  which  is 
used  later.  Alcohol,  especially  sixty  to  seventy  per  cent  alcohol,  has  a 
certain  sterilizing  action.  Alcohol  of  higher  concentration  has  less  bac- 
tericidal action,  as  it  rapidly  coagulates  the  albumen,  forming  a  coat- 
ing which  prevents  penetration.  The  skin  already  contains  some  water, 
remaining  after  the  washing,  and  seventy  or  eighty  per  cent  alcohol  is 
therefore  used. 

After  washing  in  alcohol  the  skin  shrinks,  and  the  small  furrows  and 
fissures  in  the  epidermis  in  which  the  bacteria  are  lodged  become  closed. 
Cultures  taken  at  this  time  would  probably  be  sterile,  but  the  hands 
should  not  be  regarded  as  sterile  in  the  surgical  sense,  for  as  soon  as  the 
hands  come  in  contact  with  water  or  blood  the  fissures  and  furrows 
open  and  the  bacteria  are  discharged  upon  the  surface.  For  this  reason 
the  acti(m  of  some  ant is('[)li(;  is  required. 


PREPARATION  OF  THE  SURFACE  OF  THE  BODY       57 

Bichloride  of  Mercury  Solution. — Bichloride  of  mercury,  introduced 
into  surgical  practice  by  von  Berjrmann  (1878)  and  later  recoimnended 
by  Schede,  is  still  at  the  present  the  most  powerful  chemical  anti- 
septic. 

A  1  to  2,000  solution  of  bichloride  is  employed,  tablets  prepared  by 
any  of  the  principal  chemical  manufacturers  ])eing  used  for  the  purpose. 
The  addition  of  sodium  chloride  prevents  the  decomposition  of  the  bichlo- 
ride by  the  alkalies  of  the  tap  water.  Warm  tap  water,  boiled  water,  or 
water  taken  from  a  reservoir  may  be  used  in  making  the  solution,  as 
the  bacteria  which  are  contained  in  the  water  are  killed  by  the  bichlo- 
ride after  the  solution  stands  for  some  time.  The  tablets  used  in  mak- 
ing the  solution  contain  a  stain,  and  the  solution  is  colored  so  that  it 
can  readily  be  distinguished  from  other  antiseptic  solutions  or  from 
water. 

Other  Methods  of  Hand  Sterilization. — Brief  mention  will  be  made 
of  other  methods  of  hand  sterilization.  Some  surgeons,  among  whom 
Neuber  may  be  cited  as  an  example,  regard  Avashing  with  hot  water  and 
soap  as  sufificient,  while  others,  such  as  Ahlfeld,  value  the  bactericidal 
action  of  alcohol  so  highly  that  they  regard  the  use  of  other  antiseptics 
as  superfluous.  Von  Mikulicz  attempted  to  combine  the  action  of  soap 
and  alcohol  by  using  a  mixture  consisting  of  10.2  potassium  soap,  0.8 
unsaponified  olive  oil,  1.0  glycerin,  43.0  alcohol,  and  45.0  water,  which 
was  rubbed  into  the  skin  with  a  brush.  ITaegler's  investigations  showed, 
however,  that  the  bactericidal  action  of  this  mixture  was  only  apparent, 
as  it  formed  a  thin  layer  of  soap  under  which  the  bacteria  were  retained. 
It  does  not  favor  the  separation  of  the  upper  layers  of  the  epidermis  to 
the  extent  that  soap  and  alcohol  do  when  used  separately,  and  besides 
makes  the  hands  slippery.  Soap  mixtures  naturally  prevent  the  bac- 
tericidal action  of  sublimate  solutions,  as  the  thin  layer  of  soap,  which 
remains  attached  to  the  skin,  forms  an  insoluble,  inactive  compound 
with  the  mercury.  In  spite  of  these  objections  soap  mixtures  in  solid 
form  (Vollbrecht)  or  combined  with  pumice  stone  (Pfoerringer)  may 
be  used  in  case  of  emergency,  where  the  water  sui)ply  is  low,  espe- 
cially in  battle.  It  should  be  remembered,  however,  that  they  form  but 
poor  suljstitutes  for  the  Fiirbinger  method. 

Lysol  is  preferred  by  obstetricians.  It  is  seldom  used  by  surgeons, 
as  it  renders  the  hands  slippery  and  interferes  with  the  manipulation  of 
instruments. 

Cotton  and  Euhbcr  Gloves. — The  sterilized  cotton  gloves  introduced 
by  von  IMikulicz,  which  were  put  on  after  the  hands  had  been  sterilized, 
have  found  but  few  friends.  When  used  they  nuist  be  changed  from 
five  to  ten  times  during  an  operation,  as  the  bacteria  which  come  to  the 
surface  of  the  hands  during  the  operation  become  attached  to  the  inner 


58  ASEPTIC   TECHNIC 

surface  and  may  even  be  carried  through  to  the  outer  surface.  Von 
Bergmanu,  after  a  long  and  thorough  trial,  has  discarded  them  for  oper- 
ative work,  using  them  only  when  changing  dressings,  handling  sterile 
sheets  or  towels  and  dry  instruments. 

Rubber  gloves,  recommended  first  by  von  Zoege-Manteufel,  and  per- 
fected later  hy  Friedrich,  have  a  number  of  advantages.  Rubber  gloves 
may  at  first  interfere  with  the  dexterity  of  the  operator  and  the  deli- 
cacy of  touch,  but  these  disadvantages  are  soon  overcome  when  the  sur- 
geon becomes  accustomed  to  them.  The  hands  should  be  sterilized  be- 
fore the  gloves  are  put  on.  Gloves  may  also  be  boiled  at  the  time  the 
instruments  are  sterilized.  They  are  then  filled  with  sterile  water  and 
put  on  wet.  Some  surgeons  prefer  the  dry  method,  the  hands  being 
covered  with  sterilized  talcum  powder  before  the  gloves  are  put  on, 
while  a  number  of  others  prefer  the  wet  method  of  using  gloves.  After 
they  have  been  used,  they  should  be  washed  off  with  soap  and  water, 
filled  with  gauze,  and  dried.  Gloves  should  not  be  kept  in  antiseptic 
solutions,  as  they  then  soon  lose  their  elasticity. 

[Rubber  gloves  are  being  used  very  extensively  by  American  sur- 
geons. Bacteriology  has  demonstrated  that  hand  sterilization,  regard- 
less of  the  method  employed,  cannot  be  entirely  depended  upon.  Clin- 
ical experience  has  demonstrated  the  etlectiveness  of  rubber  gloves 
in  preventing  infections,  and  although  it  has  frequently  been  demon- 
strated that  the  bacteria  of  the  skin  multiply  beneath  the  rubber,  they 
cannot  reach  the  wound  unless  the  glove  is  punctured  and  torn.  Such 
accidents  can  be  prevented  by  care,  and  after  a  little  practice  are  rec- 
ognized so  soon  that  there  is  but  slight  danger  of  infection. 

Gloves  are  especially  valuable  as  a  prophylactic  measure,  and  should 
invariably  be  worn  in  making  examinations  of  lesions  which  may  be 
specific,  and  in  examining  or  operating  upon  virulent  infections.  After 
gloves  have  been  worn,  the  operator  becomes  accustomed  to  them,  and 
they  no  longer  interfere  with  the  dexterity  of  the  surgeon  or  his  deli- 
cacy of  touch.  It  is  the  belief  of  the  editor  that  rubber  gloves  will  be 
generally  adopted,  and  that  their  introduction  into  surgery  marks  one 
of  the  greatest  advances  in  aseptic  technic] 

The  Necessity  of  Washing  the  Hands  in  Sublimate  Solution  During 
the  Operation. — The  hands,  unless  chapped  or  fissured,  may  be  regarded 
as  comparatively  free  from  germs  after  sterilization  according  to  Fiir- 
binger's  technic,  provided  they  have  not  been  in  contact  with  pus  or 
other  infectious  material,  as  the  most  refined  bacteriological  methods  fail 
to  demonstrate  any  great  number  of  bacteria  in  the  skin.  This  condition 
does  not  persist,  however,  throughout  an  entire  operation,  even  if  the 
case  is  a  clean  one  and  the  technic  is  good.  Soorf  micro-organisms,  espe- 
cially the  white  staphylococci,  appear  upon  the  surface  of  the  skin.     The 


PREPARATION  OF  THE  SURFACE  OF  THE  BODY       59 

researches  of  von  Mikulicz,  Ilaefjler,  Doederlin,  and  others  have  thrown 
light  upon  the  origin  of  these  bacteria.  A  few  are  derived  from  the 
air;  the  majority  come  from  the  deeper  layers  of  the  skin,  from  the 
outer  parts  of  the  ducts  of  the  sebaceous  and  sweat  glands,  the  hair 
follicles,  and  the  small  fissures  in  the  epidermis.  These  bacteria  hidden 
Avithin  these  retreats  have  not  been  reached  by  either  mechanical  or 
chemical  sterilization,  and  are  carried  to  the  surface  by  movements  and 
friction,  for  example,  in  tying  ligatures  and  sutures.  Therefore  the 
hands  must  frequently  be  washed  in  a  sublimate  solution,  which  should 
often  be  renewed  during  the  course  of  the  operation,  and  should  come 
in  contact  with  the  wound  as  little  as  possible,  tissue  forceps  and  other 
instruments  being  used  when  possible  (Koenig). 

Care  of  the  Hands. — The  surgeon's  hands  should  receive  good  care 
and  be  protected  from  infectious  material.  Proi)hylaxis  is  the  best  guar- 
antee against  infections.  Therefore,  rubber  gloves  should  be  worn  when 
infected  cases  are  dressed  or  operations  performed  upon  suppurating 
or  putrefactive  processes.  In  examinations  of  the  mouth  or  rectum 
gloves,  or  at  least  a  finger  cot,  should  be  worn.  After  the  operation  is 
completed,  the  bichloride  which  remains  attached  to  the  epidermis  should 
be  removed  with  hot  water  and  soap,  as  it  may  produce  in  susceptible 
people  a  vesicular  eczema  with  secondary  ulcers  and  crusts.  After  the 
last  washing,  when  the  hands  have  been  thoroughly  dried,  glycerin  or 
some  hand  lotion  should  be  rubbed  into  the  skin  to  prevent  chapping. 
An  infusion  of  bran  has  also  been  recommended  for  this  purpose  (Ilaeg- 
ler).  A  surgeon  whose  hands  are  very  rough  should  rub  glycerin  into 
the  skin  or  apply  lanolin  before  retiring,  and  wear  gloves  during  the 
night. 

►Suppurating  wounds  of  the  hands,  and  even  the  most  insignificant 
inflannnatory  processes  make  an  aseptic  operation  impossible  even  if 
gloves  are  worn. 

Sterilization  of  the  Skin  of  the  Field  of  Operation. — Each  patient 
should  be  given  a  warm  bath  some  time  before  the  operation  if  there 
are  no  contraindications.  Grosser  particles  of  dirt  (especially  upon  the 
hands  and  feet)  should  be  removed  by  vigorous  washing  with  ether,  ben- 
zine, or  petroleum  ether.  The  field  of  operation  and  the  surround- 
ing skin  should  be  shaved.  The  skin  should  ))e  shaved  even  where 
there  is  but  little  hair,  as  the  upper  loosened  epidermis  is  most  effec- 
tively removed  in  this  way.  After  the  shaving  is  completed  the 
same  technie  is  employed  as  has  already  been  described  for  hand  sterili- 
zation. 

Sterilization  of  Mucous  Membranes. — INTucous  membranes  to  be  di- 
vided in  the  course  of  the  operation  can  only  be  ineoinplctely  sterilized. 
Antiseptics  have  no  efit'eet  upon  bacteria  contaiiKd    in   the  secretion  of 


60  ASEPTIC   TECHNIC 

mucous  membranes,  and  besides  they  may  irritate  the  latter  and  be 
absorbed,  causing  severe  toxic  symptoms  (e.  g.,  bichloride  poisoning 
after  rectal  and  vaginal  irrigations).  Mechanical  sterilization  must  be 
relied  upon  in  these  cases,  a  three  per  cent  solution  of  hydrogen  peroxide 
being  used  in  the  mouth  cavity;  sterile  water  or  a  bland,  non-irritating 
solution  (three  per  cent  aluminum  acetate,  or  two  per  cent  boric  acid 
solution)  being  employed  for  bladder  and  rectal  irrigations.  During 
operations  upon  the  stomach  and  intestines  the  secretions  of  the  mu- 
cous membranes,  the  stomach  contents,  and  fsecal  matter  should  be 
carefully  wiped  away  with  gauze  sponges  or  laparotomy  pads.  The 
peritoneum  should  also  be  protected  by  laparotomy  pads  before  the 
stomach  or  intestines  are  opened,  and  contamination  of  the  peritoneum 
prevented. 

Mercurial  poisoning,  the  symptoms  of  which  are  salivation,  colic,  and 
persistent,  often  bloody  diarrhoea,  has  not  been  observed  after  the  use 
of  1  to  2,000  solutions.  Haegler  believes  that  surgeons  who  do  not  wash 
off  the  sublimate  which  becomes  attached  to  the  hands  during  sterili- 
zation may  become  slightly  intoxicated  by  touching  the  lips  with  the 
fingers. 


CHAPTER    II 

STERILIZATION    OP    INSTRUMENTS 

Instruments  are  no  longer  sterilized  by  placing  them  in  a  two  and  a 
half  per  cent  solution  of  carbolic  acid  shortly  before  or  during  an  opera- 
tion. At  the  present  time  they  are  sterilized  by  boiling,  a  rapid  and 
efficient  method.  Pyogenic  cocci  are  killed  in  a  few  seconds  and  the  re- 
sistant anthrax  spores  in  five  minutes  by  boiling.  Boiling  for  five  min- 
utes is  sufficient  in  all  cases. 

Instruments  which  are  sterilized  frequently  should  be  made  entirely 
of  steel  without  wood  or  horn  handles,  and  should  be  thoroughl.y 
scrubbed  before  they  are  boiled.  Those  soiled  during  an  operation 
should  be  rinsed  off  with  cold  water  (preferably  under  the  tap),  and 
should  then  be  allowed  to  remain  for  some  time  in  a  warm  solution  of 
soda  and  soft  soap,  scoured  and  well  dried,  and  finally  polished  with 
alcohol  and  clianiois  skin.  The  more  com})osite  instruments  (viz.,  artery 
clamps  and  forceps)  should  be  taken  apart  each  time  for  cleansing. 
Nickel  plating  of  instruments  is  not  necessary,  and  besides  it  is  not  per- 
manent. 


STERILIZATION   OF   INSTRUMENTS 


61 


Soda  Solution  and  Apparatus  for  Boiling  Instruments. — To  prevent 
the  rusting  of  steel  instruments  Schiunuelbuseh  has  introduced  the  use 
of  ordinary  cooking  soda  (1  to  100),  The  addition  of  an  alkali  not  only 
prevents  the  rusting  of  instruments,  but  also  aids  in  sterilization,  for  the 
attached  pieces  of  dirt  are  more  easily  separated  and  penetrated.  A 
tablespoonful  of  soda  is  used  in  a  liter  of  water.     The  apparatus  de- 


FiG.  43. — Schimmelbusch's  Apparatus  for  Sterilizing  Txstrumexts.  It  consists  of 
three  instrument  trays,  14X18  inches,  a  graduate  for  making  soda  solution,  wooden 
bracket  for  match  safe,  time  glass  and  soda  box.  The  ajiparatus  is  to  be  filled  with 
water  about  two  inches  deep,  to  which  a  teaspoonful  of  soda  is  to  be  added.  A  large 
gas  burner  beneath  sets  the  water  boiling  in  a  few  minutes. 


\\sed  by  Schimmelbusch,  which  is  made  in  different  forms  and  sizes,  and 
differently  equipped,  is  used  for  boiling.  The  one  per  cent  soda  solu- 
tion which  fills  this  boiler  can  be  made  to  boil  in  a  few  minutes  by  an 
electric  current,  steam,  gas,  or  spirit  lamp.  The  instruments  are  placed 
in  order  in  the  flat,  perforated  tin  tray,  which  is  submerged  in  the  solu- 
tion. The  edges  of  sharp  instruments  must  be  protected.  For  this 
reason  needles  should  be  placed 
in  small  glass  or  metal  boxes, 
and  the  knives  kept  in  a  frame 
or  the  blades  wrapped  with  cot- 
ton. The  cover  of  the  apparatus 
fits  tightly  and  the  temperature 
of  the  solution  may  be  brought 
to  220°  F.  After  boiling  for  five  minutes  or  longer,  the  tray  is  re- 
moved by  two  steel  hooks  which  are  used  for  the  purpose,  and  is 
placed  in  the  frame  of  an  instrument  table.  Hie  instruments  may 
be  cooled  by  pouring  cold  sterile  water  over  them,  or  by  placing  the 
tray  in  a  basin  of  cold  sterile  water  or  spreading  them  upon  a  sterile 
towel ;  in  the  latter  case  some  minutes  will  be  required  before  they  be- 
come cool. 


Fig.  44.  —  Kny-Scheeiu;r  Steiui.izi.ng  Pax 
WITH  Instruments  for  Use  in  Steam 
Sterilizer. 


62 


ASEPTIC   TECHNIC 


Instrument  Table. — The  instrunieiits  Avliicli  will  be  required  should 
be  placed  upon  a  table  which  is  covered  by  a  sterile  towel ;  the  other 
instruments  being  loft  on  a  tray  or  in  a  basin.  The  table  should  be  so  con- 
structed that  it  can  be 
easily  placed  near  the 
surgeon  or  attached  to 
an  upright  so  that  it 
may  be  swung  over 
the  patient.  Instru- 
ments which  have  been 
used  should  be  re- 
placed by  clean  ones 
and  should  then  be 
rinsed  ofl,  scoured, 
and  resterilized.  The 
soda  solution  should  be 
kept  in  readiness,  A 
spoon  holding  10  c.c. 
may  be  used  to  meas- 
ure the  powdered  soda 
or  soda  tablets  may  be 
used  instead. 

Sterilization  of  In- 
struments in  Private 
Practice. — The  surgeon 
is  always  able  by  the 
use  of  this  soda 
solution  to  ster- 
ilize instruments 
rapidly  and 
thoroughly  in 
the  patient's  home. 
An  ordinary  kettle,  if 
large  enough,  will  suf- 
fice. If  a  large  num- 
ber (.r  iiislniiiicnls  iimsl  he  slcrili/cd,  an  asparagus  boiler  or  a  fish  kettle 
Willi  |)(rr()ral<'(|  tray  may  be  used.  The  kettle  is  placed  in  cold  water 
aflcr  l)(»iliiig,  and  the  soda  solution  cools  rapidly,  and  the  instruments 
may  1  licri  !)(•  removed. 

Iiislnmients  should  not  be  washed  or  placed  in  sublimate  solution, 
for  they  ;ire  soon  hhiekened  by  a  deposit  of  mercury.  Syringes  which 
are  iii.Mle  (.r  metal  and  glass  and  are  provided  with  asbestos  and  glass 
pistons  may  be  sterilized   by  boiling  in  the  soda  soluti(m.     To  prevent 


Fia.  4.5. — Instrument  Table  on  Which  Stekile  Insthu- 
MENTS  Requihed  fok  Immicdiate  Use  Are  Placed. 
Tlie  table  is  provided  witli  rollers  so  that  it  can  be 
easily  moved  about  and  placed  where  convenient  for 
the  o]jei-alor. 


STERILIZATION   OF   SPONGES,   BANDAGES,  SHEETS,  AND  TOW  l.i.S      63 

the  glass  from  breaking:  the  syringe  should  be  half  filled  before  it  is 
placed  in  the  solution,  and  it  should  never  be  placed  directly  in  boiling 
\\atei'.  The  glass-rubber  syringes  cannot  be  thoroughly  sterilized,  and 
should  not  be  used.  Keeping  them  in  antiseptic  solutions  is  not  sufficient, 
as  the  number  of  infecti<ms  following  their  use  in  morphine  injections 
demonstrates.  Drainage  tubes,  silk,  metal  wire,  and  catlieters  m;iy  also 
be  sterilized  by  boiling.  Only  the  rubber  and  silver  eatheters,  however, 
stand  boiling.  If  the  catheter  has  been  used  its  surface  must  be  rubbed 
off  and  its  lumen  cleaned  by  allowing  tap  water  to  I'un  thi'ough  it. 
The  silk  catheters  covered  with  shellac  and  india  i-ublx'r  eatheters  should 
not  be  boiled,  as  they  become  soft  and  can  no  longer  be  nsed.  Accord- 
ing to  Claudius  they  stand  boiling  best  in  concenti-ated  salt  solution 
(4  NaCl :  10  water),  or  according  to  Herman,  in  a  concentrated  solution 
of  sulphate  of  ammonia  (3:5  water),  a  procedure  reconnnended  by  Els- 
berg  for  the  sterilization  of  catgut.  The  ordinary  Nelaton  catheter,  used 
so  extensively  in  America,  stands  boiling  very  well,  and  may  be  steril- 
ized with  the  instruments. 


CHAPTER    III 

STERILIZATION  OF  SPONGES,  BANDAGES,   SHEETS,  AND  TOWELS;   PREPARATION 

OF   IODOFORM    GAUZE 

Gauze,  cotton,  and  roller  bandages  are  rerpiired  in  the  dressing  of 
the  ordinary  wounds. 

Absorbent  Gauze. — Absorbent  gauze,  which  was  introduced  by  Lister, 
is  even  to-day  the  most  useful  material  for  dressing  wounds.  It  takes 
up  Avound  secretion  and  at  the  same  time  allows  it  to  dry.  None  of  the 
substitutes  which  have  been  tried  has  this  property.  The  substitutes 
are  cheaper,  but  the  absorbent  gauze  is  indispensable.  It  is  made  of 
loosely  woven  cotton  from  which  the  fat  has  been  extracted,  and  is 
sold  in  large  bolts.  These  are  cut  into  scjuare  pieces  of  about  25  qcm. 
with  heavy  scissors.  Some  of  these  are  irregularly  folded  to  form  fluffed 
gauze,  some  are  regularh'  folded  to  form  dressings  and  compresses,  or 
cut  into  long  strips  for  tampons.  A  part  of  the  fluffed  gauze  is  used 
for  sponges  by  which  the  blood  is  wiped  away  during  the  operation, 
while  large  amounts  are  used  in  dressing  the  wound. 

Cotton. — Cotton  packs  easily  when  in  contact  with  a  wound,  absorbs 
but  little  wound  secretion,  and  forms  a  layer  whicli  pi'evenfs  its  diseharge. 
It  can  never  replace  gauze,  but  it  is  soft  and  pliabh^  and  can  be  used 
to  advantage  in  padding  a  bandage.     It  is  nuide  of  bleached  raw  cotton 


64 


ASEPTIC   TECHNIC 


from  which  the  fat  has  been  extracted,  and  is  sold  in  rolls.  These  are 
cut  into  strips  about  15  cm.  in  width,  which  are  rolled.  Cotton  is  cleaner 
and  more  easily  handled  than  the 
substitutes  Avhich  have  been  intro- 
duced. The  substitutes  are,  how- 
ever, cheaper,  and  raaj^  be  used 
for  suppurating  wounds  which  are 
discharcrinfr  profusely.  Wood  cot- 
ton, made  of  wood  wool  and  cotton, 
is  rolled  and  used  in  the  same 
way   as  cotton.     Peat  and  moss, 


Fia,  47a.     I'm.,  .^i  lu,  Sikam  Dressing 
Sterilizer. 


Fig.  46. — Can  for  Sterilization  of  Dress- 
ings AND  Sponges.  (After  Schimmel- 
busch.) 

wood  wool,  cellulose,  and  other 
substitutes  are  sewed  up  in 
sterile  bags  and  used  for  dress- 
ings in  the  form  of  pads. 
Moss  felt  and  moss  pasteboard 
are  prepared  from  moss  by 
running  it  through  a  press. 
They  are  covered  with  gauze 
before  using,  and  are  espe- 
cially adapted  for  immobiliz- 
ing dressings.  After  moisten- 
ing, felt  can  be  molded  to  the 
puvt  to  which  it  is  to  be  ap- 
|)lie(l. 

Roller  Bandages. — IMuslin 
;iiid  gauze  l)an(lages  are  used 
r(»r  maintaining  the  dressings 
in  position.  Tbe  former,  made 
of     English     mull     of     strong 


STERILIZATIOX   OF   SPONGES,   BANDAGES,  SHEETS,  AXD   TOWELS      Go 

fiber,  are  expensive  l)ut  durable,  and  can  be  Mashed  and  used  repeat- 
edly.     The  gauze   rollers,   made  of  loosely   Avoven   German   mull,   are 


lie;.  476. — CoMBiXAiioN  Sterilizing  Apparatus. 


cheap  and  pliable,  but  as  a  rule  can  be  used  but  once.    Roller  bandages 
may  be  procured  ready  made  from  the  dealers,  or  long  pieces  may  be 


66  ASEPTIC   TECHNIC 

torn  or  cut  from  the  piece  and  rolled  by  machine.  A  few  turns  of 
starch  bandage  may  be  applied  over  the  roller  bandage  to  make  it  firm 
and  prevent  loosening.  Starch  bandages  may  be  ])i'epared  by  impreg- 
nating- Avide-meshed  gauze  with  starch  paste  and  allowing  it  to  dry  while 
on  tension. 

Sterilization  of  Dressings. — Materials  used  for  dressings  are  sterilized 
by  steam  in  an  apparatus  devised  for  the  purpose.  Tin  cans  of  differ- 
ent forms  and  sizes  are  filled  with  gauze,  cotton,  and  bandages,  and  are 
placed  in  the  sterilizer.  The  can  devised  by  Scliiinmell)useh  is  rouud 
or  square.  The  cover,  bottom,  and  sides  of  the  cans  are  provided  with 
a  great  number  of  holes  which  can  be  opened  and  closed  at  will  by  a 
strip  of  tin.  These  holes  permit  the  steam  to  pass  through  the  dress- 
ings. Sterilization  is  complete  in  three  quarters  of  an  hour  after  the 
steam  begins  to  form  (Schimmelbnsch,  Borchardt).  After  sterilization 
is  completed  the  cans  are  allowed  to  remain  in  the  sterilizer  for  a  short 
time  with  the  holes  open  in  order  to  allow  the  materials  to  dry. 

The  cans  are  then  closed  and  are  ready  for  use.  In  hospitals  freshly 
sterilized  cans,  some  filled  with  gauze,  some  with  cotton,  and  some  wit'h 
bandages,  are  supplied  each  morning  to  the  dressing  and  to  the  operating 
rooms. 

The  sheets,  the  large  and  small  towels  which  are  used  to  bound  the 
field  of  operation,  to  cover  the  patient,  the  operating  table,  and  the  small 
instrument  table  should  be  done  up  in  packages  and  sterilized  in  the 
steam  sterilizer.  Moss,  wood  wool,  and  peat  pads  are  handled  in  the 
same  way. 

Large  hospitals  are  provided  with  a  second  large  sterilizer  which  is 
used  for  the  larger  pieces,  the  smaller  being  sterilized  in  the  apparatus 
which  is  used  for  the  dressings.  Some  hospitals  are  provided  with  spe- 
cial steam  sterilizers  in  which  an  entire  bedstead  uuiy  be  sterilized  by 
steam   (viz.,  in  epidemics). 

Sea  spcmges,  which  were  formerly  extensively  em])loyed,  are  rarely 
used  to-day  to  sponge  wounds  or  as  tampons  (viz.,  laparotomies,  resec- 
tion of  the  maxilla).  Aseptic  gauze  is  used  instead.  Occasionally  they 
ai-e  used  upon  artery  forceps  to  wipe  out  the  larynx  and  pharynx 
during  anu'sthesia,  or  with  Beloque's  tubes  to  tampon  the  nares  in  opera- 
tions upon  the  nose  and  in  nosebleed.  Even  here  sterile  gauze  or  rolled 
iodoroi-iii  gaaze  may  he  uscmI.  Sea  sponges  do  not  stand  physical  sterili- 
zalioii  well.  Scliiuunelbusch  has  rec(mimended  that  they  be  placed  for 
one  liair  lioiii-  in  hot,  but  not  boiling,  one  per  cent  soda  solution  for 
st('i'ili/.;i1  ion. 

Preparation  of  Iodoform  Gauze. — Iodoform  gauze  can  be  prepared 
in  llii'  rnlldwing  way:  Long  doubled  strips  of  sterile  gauze  are  spread 
out    n|)oii  ;i  sterile  towel,  the  hands  having  been  previously  thoroughly 


STERILIZATION    OF   SUTURES   AND   LIGATURES  67 

sterilized.  The  fiauze  is  tlien  powdered  evenly  with  iodoform  powder. 
An  ordinary  salt  shaker  which  has  been  sterilized  may  be  used  for  this 
purpose.  The  iodoform  is  then  gently  rubbed  into  the  gauze  with  a 
sterile  sponge,  and  ironed  with  a  glass  weight  provided  with  a  handle 
(Fig.  48).  The  strips  of  gauze  are  then  rolled  and  ai-e  kept  in  a  steril- 
ized can.  If  the  strips  of  gauze  are 
sprinkled  with  a  little  sterile  water,  the 
iodoform  powder  becomes  more  easily 
attached.  When  the  gauze  is  retiuired 
for  a  tampon,  the  required  length  is 
pulled  out  from  the  roll  with  tissue 
forceps  and  cut  with  scissors.  The  can 
is  then  immediately  closed.  If  the 
gauze  contains  too  much  iodoform,  it 
can  be  shaken,  and  the  greater  part  of  i.,q  4^ 

the  powder  removed  in  this  way. 

For  minor  cases  (accidents)  the  gauze  may  be  prei)ared,  just  before 
using,  by  sprinkling  sterile  gauze  with  iodoform  powder. 

The  method  above  described  is  preferable  to  those  methods  in  which 
the  gauze  is  prepared  with  glycerin  and  colophony  or  sterilized  in 
steam.  In  the  first  method  the  capillarity  of  the  gauze  is  decreased, 
in  the  second  the  iodoform  is  decomposed.  Besides,  it  is  not  necessary 
to  sterilize  iodoform  gauze,  for  virulent  pathogenic  bacteria  have  never 
been  found  in  iodoform  powder,  and  clinically  bad  results  do  not  follow 
the  use  of  iodoform  gauze  which  is  not  sterilized  by  heat  just  before 
being  used. 

The  iodoform  gauze  sold  by  manufacturers  is  not  to  be  recom- 
mended. It  is  difficult  to  handle,  and  furthermore  the  amount  of  iodo- 
form contained  in  the  gauze  cannot  be  estimated,  and  the  sterilization 
of  the  gauze  cannot  be  depended  upon.  The  gauze  must  be  taken  from 
the  package  with  greatest  care,  to  prevent  contamination.  It  must  be 
spread  upon  a  sterile  towel  and  the  required  length  cut,  and  the  re- 
mainder of  the  gauze  must  not  be  placed  in  the  package  again,  but  must 
be  kept  in  a  sterile  can. 


CHAPTER    IV 

STERILIZATION    OF    SUTURES   AND    LIGATURES 

Silk.— Silk  may  be  sterilized  by  boiling  or  in  steam.    It  may  be  rolled 
upon  glass  or  metal  spools  and  boiled  with  the  instruments,  and  then 
kept  in  an  antiseptic  solution.     Schimmelbusch  has  devised  for  steam 
6 


68  ASEPTIC  TECHNIC 

sterilization  small  tin  boxes  which  hold  many  spools  of  silk.  These  are 
closed  Avheu  the  sterilization  is  completed.  When  opened  the  end  of 
the  thread  of  each  roll  may  be  seen  through  a  little  opening  in  the  side 
of  the  box. 

Sterilization  of  silk  by  heat  alone  is  not  sufficient.  Later  investiga- 
tions, particularly  those  of  Haegler,  have  shown  that  in  threading, 
tying,  and  passing  sutures  through  the  skin,  bacteria  become  attached 
to  the  rough  surface  of  the  silk.  These  bacteria,  while  not  very  viru- 
lent, may  develop  in  the  silk  and  produce  inflammation  and  suppura- 
tion about  the  stitch  holes.  If  the  suture  is  buried,  a  sinus  may  develop 
as  the  result  of  the  inflammation,  Avhich  continues  to  discharge  until  the 
suture  is  removed.  For  these  reasons  it  is  recommended  that  the  heat 
and  chemical  methods  be  combined  in  the  sterilization  of  silk.  In  the 
Kocher  method  the  silk  is  treated  for  twelve  hours  with  ether  and  alco- 
hol to  remove  the  fat.  It  is  then  boiled  for  ten  minutes  in  a  1 : 1,000 
solution  of  bichloride  of  mercury,  and  rolled  upon  sterilized  glass  spools 
after  the  hands  have  been  thoroughly  sterilized.  These  spools  of  silk  are 
again  boiled  in  a  1 :  1,000  solution  of  bichloride  just  before  using.  The 
albumen  of  the  silk  forms  a  chemical  union  with  the  mercury,  which  is 
slowly  extracted  by  the  juices  of  the  body.  The  mercury  gradually  dis- 
appears from  the  suture  in  five  to  ten  days,  depending  upon  its  size. 
These  small  amounts  of  mercury  cannot  destroy  bacteria,  but  they  check 
their  development  (Haegler). 

Sublimate  silk  is  especially  adapted  for  buried  sutures.  In  thread- 
ing and  handling  suture  material,  it  should  be  drawn  through  the  fin- 
gers to  remove  the  crinkles  which  are  often  present.  Rough  silk  should 
be  handled  as  little  as  possible  in  this  way. 

Silkworm  Gut. — Silkworm  gut  is  the  fiber  drawn  out  from  the  body 
of  the  silkworm  killed  just  as  it  is  ready  to  spin  its  cocoon.  The  sur- 
face of  silkworm  gut  is  smoother  than  that  of  silk,  and  therefore  bacteria 
do  not  become  attached  to  it  so  easily,  and  as  it  is  more  compact  the 
bacteria  do  not  penetrate  into  its  interior.  Silkworm  gut  is  more  expen- 
sive than  silk  and  cannot  be  used  for  fine  approximation  sutures.  It  is 
nsed  most  extensively  for  tension  sutures;  silk  or  horsehair  being 
used  for  the  finer  approximation  of  the  edges  of  the  skin.  Silkworm 
gut  may  be  sterilized  by  boiling  with  the  instruments. 

Metal  "Wire. — Metal  wire  is  used  especially  in  suturing  bone  and  for 
buried  tension  sutures.  Aluminum  bronze  wire  is  preferred,  as  it  is  duc- 
tile and  durable.  Silver  wire  is  more  rarely  used.  Wire  can  be  sterilized 
with  the  instruments  by  boiling. 

Catgut. — (Jatgut  has  the  advantage  of  being  absorbable.  It  is  ab- 
sorbed by  th(^  tissues  within  from  two  to  four  weeks,  depending  upon 
the  si/(!  of  the  catgut.    For  this  reason  it  is  especially  adapted  for  liga- 


STKKILIZATION    OF    SUTURES   AXD    LIOATURES  69 

tures.  The  attempts  to  use  catECut  for  sutures  and  ligatures  date  back  to 
the  time  of  Galen.    Lister  was  the  first  to  introduce  it  in  a  useful  form. 

Catgut  is  not  prepared,  as  the  name  suggests,  from  the  small  intes- 
tine of  the  cat,  but  from  that  of  the  sheep.  The  mucosa,  serosa,  and 
greater  part  of  the  muscularis  are  scraped  away,  so  that  only  the  elastic 
submucosa  remains. 

After  the  gross  cleaning,  which  is  repeated  several  times,  the  whole 
intestine  or  long  strips  of  it  are  twisted  together  like  hemp  rope.  Rings 
of  raw  catgut,  composed  of  strands  from  3  to  5  m.  in  length,  are  sold 
by  the  dealers.     The  grade  of  the  catgut  varies  a  great  deal. 

Raw  catgut  contains  all  sorts  of  putrefactive  bacteria  and,  besides, 
anthrax  and  tetanus  bacilli.  It  must,  therefore,  be  thoroughly  sterilized 
before  it  is  used.  Catgut  cannot  be  boiled  in  water,  as  it  curls  up  and 
becomes  brittle.  Different  methods  of  sterilization,  which  are  partly 
chemical  and  partly  physical,  have  been  introduced;  new  methods  are 
always  being  tried. 

The  method  devised  by  Saul  has  been  used  in  the  von  Bergmann 
clinic  for  eight  years.  The  catgut  is  wound  upon  glass  spools  or  slides, 
which  are  placed  in  eighty-five  per  cent  alcohol  (alcohol,  85 ;  acid-carbolic 
liquefact.,  5.;  aqua  distil.,  10).  This  solution  is  then  slowly  brought  to 
the  boiling  point,  which  is  about  168°  F.  (according  to  Saul  between 
172°  and  176°  F.).  The  spools  or  slides  of  catgut  are  allowed  to  remain 
in  the  boiling  fluid  from  five  to  fifteen  minutes,  and  then  are  either  pre- 
served in  this  solution  or  ninety  per  cent  alcohol. 

Of  the  other  methods  Hofmeister's  may  be  mentioned.  The  catgut 
is  allowed  to  remain  twenty-four  hours  in  a  two  to  four  per  cent  solution 
of  formalin,  and  then  is  placed  for  twelve  hours  in  water,  after  which 
it  can  be  boiled  in  water  from  ten  to  thirty  minutes,  but  its  absorba- 
bility is  decreased.  The  catgut  is  preserved  in  a  sublimate-glycerin-alco- 
hol solution  (0.1 :  5.0 :  100.0). 

A  simple  method,  which  has  been  tested  for  a  number  of  years  in 
the  von  Bergmann  clinic,  and  which  is  to  be  recommended  for  practical 
use,  is  the  following:  The  catgut  is  wound  loosely  upon  glass  rods  or 
spools,  which  are  placed  in  ether  for  twenty-four  hours  to  remove  the 
fat,  the  ether  being  kept  in  a  sterile  vessel.  The  ether  is  then  poured 
off  and  the  spools  of  catgut  are  placed  in  the  following  solution :  Bi- 
chloride of  mercury,  10;  absolute  alcohol,  800;  distilled  water,  200. 
This  solution  is  renewed  from  two  to  three  times  in  twenty-four  hours, 
and  is  then  replaced  by  ninety  per  cent  alcohol,  in  which  the  spools  of 
catgut  are  kept.  If  the  catgut  is  too  hard,  glycerin  (20:100)  may  bo 
added. 

In  the  Claudius  method  the  eatgut  is  wound  upon  glass  slides  or 
rolls,  and  is  then  placed  in  an  aqueous  iodin-  potassium-iodid  solution 


70  ASEPTIC   TECHNIC 

(iodin  1,  potassium  iodid  1,  water  100).  This  solution  is  prepared  in 
the  following-  way:  The  potassium  iodid  is  first  dissolved  in  a  small 
amount  of  water,  and  then  finely  powdered  iodin  is  added.  The  con- 
centrated solution  is  then  diluted  until  a  one  per  cent  solution  is  made. 
After  remaining  for  eight  days  in  this  solution  the  catgut  is  ready  for 
use.  Shortly  before  the  catgut  is  used  it  should  be  placed  for  a  while 
in  a  three  per  cent  carbolic  or  other  sterile  solution  to  remove  the 
excess  of  iodin.  Catgut  not  used  during  an  operation  should  be  re- 
placed in  the  solution,  which,  according  to  Martina,  should  be  changed 
each  month.  Catgut  prepared  by  this  method  becomes  black.  It  re- 
mains elastic,  unless  allowed  to  lie  too  long  a  time,  when  it  becomes 
brittle. 

Bartlett,  of  St.  Louis,  has  devised  a  method  for  sterilizing  catgut 
which  has  proved  to  be  highly  satisfactory.  Catgut  prepared  by  his 
method  is  used  by  a  number  of  prominent  American  surgeons. 

He  describes  the  method  as  follows : 

"  The  process  can  be  divided  into  three  stages:  (1)  The  physical 
preparation  of  the  material;    (2)    its  sterilization;    (3)    its   storage. 

"  1.  The  ordinary  commercial  ten-foot  catgut  strand  is  divided  into 
four  equal  lengths,  each  of  which  is  made  into  a  little  coil  about  one 
and  a  half  inches  in  diameter.  By  twisting  the  last  free  end  about 
four  times  around  this  little  coil  the  latter  will  maintain  its  shape. 
These  coils  in  any  desired  number  (I  usually  make  about  a  hundred 
and  twentj^  at  a  time)  are  strung  on  a  thread  like  beads,  in  order  that 
the  whole  number  may  be  handled  at  once.  This  string  of  coils  is  hung  in 
a  metal  can — better  still,  in  a  beaker  glass — but  is  not  allowed  to  touch 
the  bottom  or  sides.  I  suspend  them  by  carrying  the  two  ends  of  a 
thread  through  a  small  opening  in  a  pasteboard  cover  which  is  placed 
on  the  receptacle.  The  same  opening  serves  to  admit  a  thermometer, 
which  is  cai-ried  down  to  exactly  the  point  where  the  mercury  bulb  is 
on  a  level  with  the  topmost  coils.  Liquid  petrolatum  is  now  poured  in, 
Ihc  (|uantity  being  sufficient  to  immerse  the  catgut  and  the  bulb  of  the 
thermometer. 

"  2.  Tlic  vessel  is  set  on  a  pan  of  sand,  under  which  is  placed  a  tiny 
g;is  fhmie  of  merely  sufficient  intensity  to  raise  the  temperature  of  the  oil 
1o  212"  F.  within  from  one  to  two  hours.  A  little  practice  enables  one 
to  guess  the  size  of  fhime  necessary  for  this  purpose.  This  is  best  done 
in  the  evening,  and  llie  temperature  allowed  to  remain  at  about  212°  F. 
( ;i  few  degrees'  vai'iation  does  not  matter)  until  morning.  The  heat  is 
llieii  iiiereased  1o  siicli  ;iii  exieiil  lliat  the  tem]>erature  will  run  up  to 
;{00°  F.  in  ill!  hour:  llic  giis  is  tlicn  liinied  off  and  llie  leiiip(»rature  of 
tJK!  oil  allowed  to  return  to  212  . 

"  3.  The  pasteboard  cover,  together  with  the  string  of  catgut  coils, 


OPERATING   ROOM  71 

is  lifted  off,  the  superfluous  oil  is  allowed  to  drop  off,  and  then  the 
thread  is  cut,  allowing  the  coils  to  drop  into  the  following  mixture: 

"  Columbian  spirits    100  j)iirts; 

lodin  flakes 1   part. 

"  The  catgut  is  now  ready  for  innnediate  use,  and  will  keep  without 
deteriorating  for  any  length  of  time.  The  jar  may  be  opened  any 
number  of  times,  so  long  as  a  sterile  instrument  is  used  for  removing 
the  coils,  since  the  iodin  protects  the  coils  that  are  left  behind  from 
accidental  contamination." — (Surgerij,  Gyncecolof/y,  and  Ohstetrics,  Au- 
gust, 1906.) 

Reindeer  tendon  sutures,  which  are  absorbable,  have  been  used 
(Greife).  Kangaroo  tendon  has  also  been  employed.  Some  surgeons 
(Kocher,  Witzel,  and  others)  have  discarded  catgut,  and  use  sublimate 
silk  for  ligation. 


CHAPTER    V 

OPERATING   ROOM 

Construction  and  Situation. — Every  operating  room  should  be  so  con- 
structed that  it  may  be  thoi'oughly  cleaned,  should  be  well  lighted,  and 
so  situated  that  it  may  be  easily  reached  from  all  parts  of  the  hospital. 
In  order  to  meet  the  first  requirement  the  walls,  floor,  and  all  the  objects 
in  the  room  must  be  made  of  materials  which  will  not  be  injured  by 
frequent  washing  with  soap  and  washing  soda.  The  walls  should  be 
made  of  tile,  cement,  glass  or  marble  slabs,  or  should  be  enameled.  The 
floor  should  be  made  of  tile,  cement,  or  other  similar  materials.  The 
operating,  instrument  and  bandage  tables  and  the  stands  for  basins 
should  be  made  of  enameled  \von  with  wood,  glass,  or  metal  toj^s.  and 
should  be  as  simple  as  possible  in  construction.  Thei-e  should  be  no 
decorations  on  walls  or  ceiling,  no  coi-nci-s  oi'  angles  whcM'e  dust  might 
collect.  The  floor  should  be  provided  with  a  drain.  Care  should  be 
exercised  that  grosser  particles  of  dirt  and  highly  infectious  materials 
are  not  carried  into  the  room  where  aseptic  operations  are  performed. 

Rooms  Reserved  for  Clean  and  Infected  Cases. — For  this  reason  every 
large  hospital  has  two  operating  rooms;  one  is  reserved  for  clean  eases, 
the  other  for  infected  cases.  A  suppurating  wound  should  not  even  be 
dressed  in  a  clean  room.  Larger  hospitals  have  a  large  clinical  amphi- 
theater, a  small  operating  room,  in  which  such  operations  as  a  trache- 
otomy upon  a  patient  with  diphtheria  might  be  performed,  and  special 
dressing  rooms.     In  this  way  the  ase[)tic  operating  room  is  protected 


72  ASEPTIC   TECHNIC 

from  contamination.  Some  surgeons  demand  that  an  adjacent  room  be 
used  for  washing,  in  order  that  they  as  well  as  the  patient  may  be  com- 
pletely prepared  before  entering  the  operating  room. 

In  clinical  amphitheaters  which  are  used  for  teaching  purposes,  it  is 
impossible  to  divide  the  material  into  clean  and  suppurating  cases.  Quan- 
tities of  dirt  are  always  carried  in  by  those  attending  the  clinics,  and  the 
cleaning  of  the  room  must  be  more  thoroughly  done  and  the  clean  cases 
should  be  operated  on  first.  Daily  experience  in  a  large  clinic  demon- 
strates that  these  precautions  are  sufficient. 

Cleaning  of  the  Operating  Rooms. — The  operating  rooms  should  be 
cleaned  daily  after  the  operations  are  completed.  The  floors  and  the 
walls  to  the  height  of  about  2  m.  should  be  scoured  with  washing  soda 
and  green  soap  and  rinsed  off  with  water.  A  garden  hose  attached  to  a 
faucet  may  be  used  for  this  purpose.  The  operating,  instrument,  and 
bandage  tables  and  stands  for  basins  should  be  cleansed  in  a  similar 
way.  The  enameled  basins  should  be  washed  with  soap  and  water  and 
sterilized  in  a  large  steam  sterilizer.  The  windows  of  the  operating 
room  should  be  left  open  for  some  time  after  each  cleaning.  The  air 
is  purified  in  this  way. 

Skylight  and  Arrangements  for  Artificial  Light. — An  operating  room 
should  be  lighted  by  a  skylight  and  wide  side  windows.  If  the  ceiling  is 
low  and  the  windows  high  the  skylight  may  be  dispensed  with.  Usually 
the  operating  room  is  built  so  that  it  juts  out,  and  thus  three  sides  remain 
free  and  may  be  provided  with  large  windows.  As  the  glass  is  covered 
quickly  with  moisture  and  the  water  drips  off,  each  window  should  be 
provided  with  a  small  drain.  A  double  skylight  is  used  to  prevent  the 
collection  of  moisture. 

Electric  light  is  preferred  for  artificial  illumination.  This  is  used 
in  the  form  of  a  large  portable  incandescent  light,  provided  wdth  a 
reflector,  which  can  be  brought  near  the  field  of  operation.  A  large 
number  of  incandescent  lights  arranged  in  a  circle  under  a  reflector  is 
the  most  convenient  form.  If  gas  must  be  used,  a  number  of  burners 
which  are  provided  with  glass  globes  should  be  grouped  under  a  shield. 

Construction  of  Operating  Tables.— Opernting  tables  are  differently 
constructed.  They,  likewise  the  instrument  table  and  cabinets,  must  be 
so  made  that  they  may  be  easily  cleaned,  so  that  they  will  stand  frequent 
scouring.  Therefore  only  tables  which  are  made  of  iron  with  glass,  tin, 
metal,  or  wood  tops  should  be  used.  The  construction  should  be  simple 
and  strong.  The  table  sliould  be  provided  with  a  movable  head  piece, 
the  mi(hlle  piece  so  unulv  tliat  it  may  be  elevated  or  depressed,  the  leg 
rests  shoiihl  be  detachalile,  and  provision  should  be  made  for  the  use 
of  stirrups  and  Tor  placing  the  ])atient  in  the  Trendelenburg  and  other 
[)Ositi(»ns. 


THE   ASEPTIC   OPERATION  73 


CHAPTER   VI 

THE   ASEPTIC    OPERATION 

Preparation  of  the  Patient. — Tho  patient  should  be  fjiven  a  warm 
bath  before  the  operation  if  his  condition  permits.  This  is  the  first  step 
in  the  preparation  of  the  patient,  excepting,  of  course,  those  which  are 
required  to  prepare  for  anasthesia.  He  should  be  clothed  in  clean  linen 
and  placed  upon  an  operating  cart  or  in  a  freshly  prepared  bed,  and 
talvcn  to  the  anteroom  of  the  operating  room  and  anaesthetized.  AVhen 
the  stage  of  excitement  is  passed  the  clothes  should  be  removed  and  the 
patient  covered  with  sterile  towels  and  then  lifted  onto  the  operating 
table.  This  should  be  done  slowly  and  carefully,  the  ana-sthetist  holding 
the  head,  an  assistant  taking  the  feet,  and  two  strong  assistants  standing 
opposite  placing  corresponding  hands  upon  the  sacrum  and  lumbar  re- 
gion. In  this  way  the  heaviest  patient  may  be  lifted  upon  the  operating 
table,  and  from  the  table  to  the  bed.  A  broad  rubber  sheet,  which  should 
be  changed  before  each  operation  should  cover  the  table.  A  sterile  sheet 
should  be  laid  over  this.  The  head  roll  which  keeps  the  head  in  correct 
position  during  anesthesia  should  be  placed  in  a  sterile  pillow  slip  and 
placed  under  the  neck  or  head  as  required.  Sandbags  and  rolls,  which 
are  often  required  to  secure  the  proper  positions  in  many  operations 
(e.  g.,  kidney  operations),  should  be  covered  with  sterile  towels  or  with 
sterile  bags. 

Sterilization  of  the  Field  of  Operation. — A  sterile  assistant  sterilizes 
the  field  of  operation  and  the  area  surrounding  it  for  some  distance. 
In  an  operation  upon  the  foot,  the  entire  extremity ;  in  an  operation  on 
the  breast,  the  thorax,  half  of  the  back,  and  the  arm  on  the  same  side 
should  be  sterilized.  Wounds,  fistula^,  ulcers,  or  ulcerated  tumors  which 
are  present  in  the  field  of  operation  .should  be  covered  with  sterile  gauze 
while  the  surrounding  area  is  sterilized.  In  this  way  the  carrying  of 
infection  to  the  adjacent  tissues  will  be  prevented.  Suppurating  ulcers 
should  be  covered  with  iodoform  gauze  and  adhesive  plaster  or  thor- 
oughly cauterized  with  a  Paquelin  cautery. 

When  the  cleansing  is  completed,  the  patient  is  elevated  and  the  wet 
towels  are  removed.  The  rubber  sheet  and  the  patient's  back  are  dried, 
and  a  warm  sterile  sheet  which  covers  the  entire  table  and  the  head  roll 
is  placed  under  him.  It  is  best  to  prepare  the  patient  in  the  anteroom 
upon  an  operating  cart,  and  when  fully  prepared  he  can  be  lifted  onto 
the  operating  table.  Sterile,  warm  towels  are  then  si)read  over  the  pa- 
tient and  the  hair  is  covered  with  a  hand  towel.  Only  the  face  and  the 
field  of  operation  to  the  extent  of  the  proposed  incision  should  be  exposed. 


74  ASEPTIC   TECHNIC 

# 

The  towels  last  applied  should  be  fastened  together  by  safety  pins  or 
artery  forceps,  being  used  in  this  way  in  preference  to  the  ordinary 
laparotomy  towels.  Towels  soiled  during  the  operation  should  be  re- 
placed by  clean  ones.  Packages  of  clean  sterile  towels  should  be  placed 
upon  the  top  of  the  sterilizer.  They  become  warm,  and  when  applied 
prevent  the  patient  from  becoming  cool,  and  render  the  use  of  a  table 
which  may  be  heated  superfluous. 

The  anaesthetist  should  hold  a  sterile  towel  in  front  of  the  patient's 
face  to  protect  the  wound  from  the  patient's  breath,  particularly  from 
expectoration,  vomitus,  and  particles  expelled  by  coughing. 

Preparation  of  Surgeon  and  Assistants,  and  Arrangement  of  Instru- 
ments, Sponges,  etc. — All  those  taking  part  in  the  operation  should  put 
on  sterile  linen  gt)wns  after  their  hands  are  sterilized.  Rubber  aprons 
may  be  worn  under  the  gowns  to  protect  the  clothing.  Finger  rings 
should,  of  course,  be  removed. 

The  instruments  and  dressings  should  be  placed  near  the  operator. 
A  trained  nurse,  who  has  been  trusted  with  the  preparation  of  the  instru- 
ments, arranges  them  in  order  upon  a  table  which  is  covered  by  a  sterile 
towel.  She  replaces  the  instruments  used  during  the  operation  by  fresh 
ones,  hands  instruments,  sutures,  and  ligatures.  The  sponge  box  should 
be  placed  near  the  surgeon,  so  that  he  can  help  himself  to  instruments 
and  sponges  as  much  as  the  character  of  the  operation  permits.  Basins 
filled  with  sublimate  solution  should  be  placed  near  him,  so  that  he  can 
wash  his  hands  repeatedly  during  the  operation. 

The  instruments  and  sponges  should  be  handled  as  little  as  possible. 
Only  the  operator  sliould  put  his  hand  in  the  wound,  and  he  only  in 
case  it  cannot  be  avoided  (laparotomy,  etc.).  Many  manipulations  may 
be  performed  with  tissue  forceps  and  sterile  gauze.  For  this  reason  many 
surgeons  allow  their  assistants  merely  to  hold  retractors  or  to  hold  and 
steady  tissues  (flaps  in  plastic  operations,  intestinal  loops)  with  layers 
of  gauze.  As  a  rule,  the  operator  will  be  able  to  apply  artery  forceps 
and  ligatures.  We  know  that  it  is  impossible  to  keep  the  hands  sterile 
during  the  progress  of  an  operation,  and  it  should  be  an  invariable  rule 
to  wash  the  hands  and  the  skin  adjacent  to  the  incision  frequently  with 
siibliiiiatc  stiliition  or  sterile  water  in  order  to  remove  the  blood  in  which 
the  bacteria  lodge. 

Air  Infection. — Besides  the  contact  infection,  which  may  be  prevented 
by  lliorouulily  sterilizing  the  hands  and  ol)serving  other  precautions,  air 
i)ifection  must  be  considci-cd.  Air  infection  is  usually  not  to  be  feared, 
for  tile  ail-  (tf  a  thoroughly  cleaned  operatitig  room  contains  but  few 
pathogenic,  bacteria  (Schiiiunelbusch,  Syiiniies).  The  wound  may  be- 
come inrectiMJ  il"  Uie  room  is  dusly  or  if  drops  of  Ihiid  rrem  the  patient's 
or  surgeon's  nioulli  gain  access  to  il.     IF  Ihe  sui-geon  couuhs,  sneezes,  or 


THE   ASEPTIC   OPERATION  75 

speaks,  small  drops  of  fluid  may  be  carried  into  the  wound,  and  he  should 
therefore  exercise  due  precautions.  Experience  has  demonstrated  that  air 
infection  may  be  prevented  if  the  arrangements  in  the  operating  room  are 
correct  and  due  precautions  are  taken.  The  operating  room  should  not 
be  cleaned  just  before  an  operation,  and  it  is  not  necessary  between  each 
operation.  Soiled  sponges  and  linen  should  not  be  tlirown  upon  the 
floor,  but  in  pails  or  basins,  and  dressings  should  not  be  changed  just  be- 
fore or  during  an  operation.  Anyone  with  a  nasal  or  pharyngeal  catarrh 
should  remain  at  some  distance  from  the  operation,  and  in  speaking, 
sneezing,  or  coughing,  the  head  should  be  turned  away  from  the  field  of 
operation.  A  towel  should  be  held  in  front  of  the  patient's  mouth  and 
there  should  be  no  draughts.  [The  mouth  masks  introduced  by  von 
Mikulicz,  and  the  gauze  veils  preferred  by  other  operators,  are  of  great 
importance  and  should  be  worn  by  the  surgeon  and  his  a.ssistants.] 

The  wound  should  be  kept  covered  with  gauze  as  nuich  as  possible. 
This  is  the  best  protection  against  infection,  and  besides  it  controls  capil- 
lary hamiorrhage  and  prevents  the  surface  of  the  wound  from  the  harjii- 
ful  effects  of  drying.  Some  surgeons  prefer  compresses  wliich  have  been 
moistened  with  warm  physiological  salt  solution. 

The  more  rapidly  the  operation  is  performed,  the  less  the  danger  of 
hand  and  air  infection.  For  this  reason  an  operation  should  not  be 
delayed  by  needless  conversation  and  indecision.  In  this  way  the  time 
of  anaesthesia  is  lessened  and  the  general  condition  improved.  A  super- 
ficial shoAvy  operation  should,  however,  never  be  performed  at  the  ex- 
pense of  asepsis  and  thoroughness. 

Schloft'er  and  Brunner  and  others  have  demonstrated  that  even  in 
wounds  which  heal  by  primary  intention,  large  numbers  of  bacteria  may 
be  found  a  few  hours  after  operation.  These  bacteria  come  especially 
from  the  skin  of  the  hands,  and  fortunately  are  rarely  pathogenic  and 
virulent.  It  is  difficult  to  predict  how  these  bacteria  will  act,  therefore 
it  is  a  rule  that  the  surgeon  should  not  come  in  contact  with  pus.  faeces, 
and  highly  infectious  material.  For  this  reason  all  examinations,  oper- 
ations, and  change  of  dressings,  in  which  this  is  unavoidable,  should  be 
made  with  rubber  gloves.  Virulent  bacteria,  once  having  invaded  the 
furrows  and  fissures  of  the  skin,  are  as  difficult  to  remove  as  the  harmless 
bacteria  ordinarily  found  there.  These  bacteria  mny  i-each  the  surface 
during  the  operation  and  be  transplanted  into  the  wound.  Therefore 
it  has  become  a  rule,  which  is  based  upon  clinical  experience,  never  to 
open  a  phlegmon  just  b(^fore  an  aseptic  operation. 

The  Necessity  of  Avoiding  Hough  Manipulations,  Lacerations,  or 
Crushing  of  the  Tissues. — Tlic  l)actfri;i  iiitroducfd  into  the  wound  dur- 
ing an  operation  usually  do  not  interfere  with  jirimary  healing,  as  they 
are  attenuated  and  are  destroyed  by  the  bactericidal  jiroperties  of  the 


76  ASEPTIC   TECHNIC 

tissues.  If  the  tissues  are  roughly  handk^d,  torn,  or  crushed  during  the 
.operation  these  bacteria  may  develop  and  cause  infiamraation.  Accu- 
mulations of  blood  and  Avound  secretion  also  favor  their  development. 

Incisions  should  therefore  be  clean  cut,  and  blunt  dissections  with 
tissue  forceps  and  gauze  should  be  made  only  in  loose  tissues.  Thorough 
control  of  haemorrhage  and  rational  wound  treatment  counteract  the 
growth  of  bacteria.  The  more  one  is  compelled  to  handle  wound  sur- 
faces, the  longer  they  are  exposed,  and  the  more  they  are  contused,  the 
greater  the  possibilities  of  infection.  If  it  is  probable  that  there  will  be 
a  large  amount  of  Avound  secretion,  provision  should  be  made  for  its 
escape,  and  for  this  purpose  spaces  left  between  the  sutures  and  deep 
cavities  should  be  drained  and  tam.poned. 

The  Duties  of  the  Operator. — The  operator  is  not  only  responsible  for 
the  operative  Avork,  but  superintends,  as  far  as  he  is  able,  the  asepsis  and 
the  administration  of  the  amvsthetic.  In  order  that  he  may  do  this,  the 
discipline  of  his  help  must  be  perfect,  and  all  his  wants  must  be  immedi- 
ately and  correctly  attended  to.  For  this  reason  most  surgeons  prefer 
to  operate  Avith  their  own  assistants  and  nurses. 

Closure  of  the  Wound. — An  aseptic  operation-Avound  is  closed  by  su- 
tures or  by  a  plastic  operation  after  the  haemorrhage  has  been  con- 
trolled. WhereA'er  it  is  probable  that  there  Avill  be  a  large  amount  of 
Avound  secretion,  its  accumulation  should  be  prevented. by  leaving  spaces 
betAveen  the  sutures,  in  Avhich  should  be  inserted  strips  of  iodoform 
gauze  or  gutta  percha.  This  is  necessary  particularly  after  the  division 
of  a  large  number  of  lymphatics  (axillary  fossa,  inguinal  region,  neck), 
and  where  ha'morrhage  cannot  be  perfectly  controlled,  as  in  operating 
upon  a  tumor.  A  tubular  drain  should  be  inserted  in  deep  cavities, 
which  experience  teaches  secrete  profusely,  as  is  the  case  after  the 
axillary  fcssa  is  cleaned  out.  There  is  no  danger  that  bacteria  will  de- 
A^elop  along  the  tube,  for  they  do  not  pass  against  the  current  of  wound 
secretion.  Compression  of  the  wound  by  bandages  prevents  the  accumu- 
lation of  Avound  secretion,  and  a  graduated  gauze  compress  exerting  gen- 
tle pressure  should  be  laid  over  the  deep,  sutured  wound,  such  as  is  made 
in  the  cxtirpntidii  of  a  tumor,  and  held  in  place  by  adhesive  straps. 

The  Dressing  of  Aseptic  Operation  Wounds. — As  a  rule,  sutured  opera- 
tion-wounds are  covered  Avith  a  sufficient  number  of  sterile  dressings, 
oA'er  Avhich  cotton  is  laid.  The  dressings  are  so  arranged  that  evapora- 
tion of  the  Avound  secretion  will  not  be  interfered  Avith.  The  gauze  should 
dry  the  wound  secretion  to  prevent  the  development  of  bacteria  and 
decomposition,  l^ony  prominences  should  be  covered  Avith  cotton,  and 
a  rollci-  bandage  ai)|)lic(|  evenly,  but  Avith  not  too  great  pressure.  On  the 
extrciiiitics  the  roller  hatidagc  should  always  be  ^applied  from  the  pe- 
i'il)hef\'  toward  tlie  trunk.     A  feAV  turns  of  a  juoist  starch  bandage  may 


THE   ASEPTIC   OPERATION  77 

be  applied  over  the  roller  to  make  it  linn.  As  any  movement  may  do 
harm  to  operation-wounds,  immobilizing  papier  maclie.  wood,  or  tin 
splints  well  padded  with  cotton  are  often  used. 

An  anaesthetized  patient  may  be  carefully  held  in  a  half-sittin,";  pos- 
ture while  a  bandage  is  applied  to  the  thorax.  In  apj^lying  bandages  to 
the  pelvis  or  abdomen  a  pelvic  support,  made  of  metal  so  that  it  may 
be  sterilized,  is  freijuently  used. 

Immediate  After  Care  of  the  Patient. — After  the  bandage  has  l)een 
applied  the  patient  should  be  carefully  placed  in  a  warm  bed  and  a 
warm,  dry  shirt  put  on.  The  operator  should  see  that  the  position  in 
bed  is  correct,  the  head  being  but  slightly  elevated.  If  the  extremities 
have  been  operated  upon  they  should  be  elevated  and  supported  b}'  pil- 
lows or  sandbags,  and  movement  should  be  prevented  by  the  use  of 
sandbags  placed  on  either  side.  The  bedclothes  and  shirt  should  be 
smooth,  particularly  about  the  coccyx  and  sacrum,  for  wrinkles  may  rap- 
idly produce  decubitis.  A  rub])er  cushion  filled  with  water  should  be 
placed  under  the  sacrum  of  old  and  emaciated  patients.  It  is  agreeable 
to  many  patients  to  have  a  pillow  or  roll  placed  under  the  knees  (espe- 
cially after  abdominal  operations).  I\Iany  patients  who  have  been  able 
to  be  about  before  the  operation,  complain  of  severe  lumbar  pain,  which 
often  lasts  for  a  week.  This  pain  is  often  controlled  by  placing  a  soft 
roll   under   the  sacrum-,  fi'ecpientl^y   morphine   is  recpiii-ed. 

The  pain  in  the  wound  usually  disappears  after  one  half  hour,  and 
if  the  patient  does  not  recover  from  the  anaesthetic  rapidly  it  is  scarcely 
perceptible. 

]\Iost  patients  do  not  sleep  the  night  following  the  operation.  This 
is  due  to  the  discomfort  caused  by  the  quiet  position,  the  excitement 
of  the  operation,  and  the  after  eifects  of  the  anu'sthetic  rather  than  to 
the  pain.  [Narcotics,  such  as  morphine,  should  be  dispensed  with  in  the 
after-treatment  if  possible.] 

The  excitement  of  the  patient,  which  results  partly  from  the  opera- 
tion, partly  from  the  anaesthetic,  is  best  controlled  by  quiet  and  rest. 
As  soon  as  the  patient  is  awake  a  short  and  comforting  statement  shouKl 
be  made  concerning  the  operation  and  the  prospects  of  a  rapid  conva- 
lescence. It  is  the  custom  of  many  surgeons  to  discoui*se  at  length  upon 
the  condition  of  the  patient  and  to  give  a  correct  prognosis.  This  should 
not  be  done,  as  it  disquiets  the  patient  and  often  the  statements  of  the 
surgeon  are  misunderstood. 

During  the  after-treatment  the  wants  of  the  patient  should  be  at- 
tended to  and  his  confidence  retained. 

The  nourishment  during  the  first  few  days  should  be  strengthening 
and  nutritious,  but  the  after  effects  of  the  anaesthetic  should  be  kept 
in  mind.     Special  orders  for  feeding  should  be  given  after  operations 


78  ASEPTIC  TECHNIC 

upon  the  stomach.  Alcoholic  drinks  should  only  be  prescribed  when 
the  patient  is  a  drinker.  Patients  may  be  allowed  to  smoke  if  accus- 
tomed to  it,  provided  there  are  no  diseases  of  the  respiratory  tract. 

Increasing  pain  in  the  wound  and  an  elevation  of  temperature  indi- 
cate some  disturbance  in  wound  healing.  Severe  infections  begin  with 
a  chill;  the  temperature  reaches  102°  F.  and  is  higher  instead  of  lower 
on  the  following  day.  If  this  happens  the  dressings  should  be  imme- 
diately changed,  some  sutures  removed,  and  a  light  dressing  applied 
without  pressure.  If  the  temperature  does  not  subside  more  sutures 
should  be  removed  and  the  wound  tamponed  and  drained. 

Mild  inflammation  of  stitch  holes  is  indicated  after  a  few  days  by  a 
slight  elevation  of  temperature  and  some  pain. 

Frequently  the  evening  temperature  on  the  day  following  the  opera- 
tion will  reach  101°  F.  If  it  is  higher  on  the  second  day,  the  proba- 
bilities are  that  the  wound  is  infected;  if  lower,  it  is  probable  that  the 
temperature  will  soon  return  to  the  normal  and  that  healing  will  occur 
by  primary  union.  Fever,  which  is  never  accompanied  by  general  symp- 
toms and  soon  subsides,  frequently  develops  at  the  end  of  the  first  or  the 
beginning  of  the  second  day  following  the  operation.  The  cause  of  this 
fever  is  not  known.  It  has  been  suggested  that  it  follows  the  absorption 
of  fibrin  ferment,  and  has  been  called  ferment,  aseptic,  or  noninfectious 
fever.  It  will  be  discussed  more  fully  in  the  chapter  devoted  to  the  gen- 
eral discussion  of  fever  (p.  167). 

Pain  in  the  wound  and  slight  elevation  of  temperature  without  gen- 
eral symptoms  are  frequently  caused  by  an  accumulation  of  blood.  The 
dangers  which  follow  infection  of  hannatomas  often  deter  the  surgeon 
from  opening  the  wound  and  removing  the  clots.  If  a  large  hasmatoma 
develops  and  it  is  probable  that  large  vessels  are  bleeding,  the  wound 
should  be  opened  widely,  the  clots  removed,  the  vessels  caught  and  li- 
gated.  Asepsis  should  be  as  perfect  as  in  an  operation.  After  the  ha='m- 
orrhage  is  controlled,  the  wound  should  be  resutured,  the  sutures  being 
placed  at  wide  intervals,  and  drainage  with  iodofoi-m  gan/.e  should  be 
maintained  for  some  days. 

If  the  clinical  course  of  a  sutured  wound  is  undisturbed  the  dress- 
ings may  be  removetl,  as  a  rule,  in  from  one  week  to  ten  days.  If  the 
wound  is  tamponed  or  drained  the  dressings  should  be  changed  after 
five  days  or  earlier.  After  the  removal  of  sutures,  drainage  tubes,  and 
tampons  the  edges  of  small  wounds  may  be  drawn  together  with  gauze 
iind  adhesive  plaster.  If  the  wound  is  large,  immobilization  and  com- 
pression may  bc^  rc(iuired  for  a  longer  period. 

Dressings  should  In;  changed  ni)on  an  operating  cart  or  table,  if 
the  patient's  condition  permits,  and  not  in  bed.  While  the  dressings  are 
heing  changed,  the  bed  should  l)e  freshlv  made. 


ASEPSIS   AND  THE  ASEPTIC  Oi'ERATU^N    IN    PRIVATE   PRACTICE      79 

CHAPTER    VII 

ASEPSIS    AND    THE    ASEl'TIG    OPERATION    IN    PRIVATE   I'RACTICE 

The  aseptic  technic  of  the  surf^eoii  who  is  compelled  to  perform  minor 
and  emergency  operations,  such  as  strangulated  hernias,  tracheotomies, 
appendectomies,  and  amputations  for  crushing  injuries,  and  to  care 
for  wounds  in  patients'  homes  nnist  he  simple,  yet  effective.  A  cer- 
tain equipment  is  re<iuired  as  the  foundation  of  his  surgical  activity, 
such  as: 

1  apparatus  in  which  both  instruments  3  gowns. 

and    dressings    may    be    sterilized  6  to  12  rough  hand  towcjls  made  of  linen. 

(Fig.  47a,  p.  64),  or  1  instrument    case    in    which    to    keep 

1  small  steam  sterilizer  and  instruments. 

1  can  for  dressings  (Figs.  43,  46)  and  10  bristle  brushes. 
1  instrument  boiler. 

Gauze  and  cotton  may  be  bought  in  large  packages  of.  the  dealer 
direct,  and  cut  into  required  sizes  and  lengths  when  needed.  One  or 
two  rolls  of  sterilized  gauze  and  a  roll  of  iodoform  gauze  should  always 
be  included. 

Gauze  and  starch  bandages  should  be  bought  of  the  dealers.  Drug- 
gists ask  a  very  high  price  for  these,  and  it  is  nuich  cheaper  to  buy  them 
from  the  manufacturer  direct. 

Rubber  drainage  tubes  should  be  boiled  with  the  instruments  and 
fenestrated  with  curved  scissors  just  before  being  used. 

Sufficient  amounts  of  silk  and  catgut  should  always  be  kept  in  readi- 
ness. Silk  should  be  w^ound  on  glass  slides,  catgut  upon  glass  spools. 
The  former  should  be  boiled  and  preserved  in  an  alcoholic  solution  of 
sublimate;  the  latter  after  special  preparation  should  be  preserved  in  an 
alcoholic  sublimate  or  iodin  solution.  The  jars  in  which  the  silk  and 
catgut  are  preserved  should  be  provided  with  closely  fitting  tops. 

Rubber  catheters  should  be  sterilized  by  boilii'g  just  before  they  are 
used. 

The  surgeon  may  prepare  his  own  ])1  aster  of  Paris  bandages,  or  buy 
them  of  the  dealers  or  druggists.  In  preparing  these  a  dry  starch  band- 
age is  spread  out  upon  a  board  and  plaster  of  Paris  is  sprinkled  over 
it  and  rubbed  in  evenly  with  the  edge  of  a  ruler.  The  bandages  are  then 
loosely  rolled  and  placed  in  tin  cans  to  protect  them  from  moisture. 

Papier  mache  splints,  made  by  papier  maclie  manufacturers.  G  cm. 
broad  and  1  m.  long,  may  be  used  for  immobilizing  divssings.  'Hiese 
splints  may  be  molded  to  fit,  and  are  more  practical  than  the  wood  and 
tin  splints,  which  rarely  fit. 


80 


ASEPTIC   TECHNIC 


The  things  required  for  an  operation  should  be  prepared  and  packed 
in  the  following  way : 

(a)  For  a  minor  operation  (felon,  incision  of  a  boil,  excision  of  an 
atheroma,  etc.),  the  following  instruments  should  be  boiled: 

2  knives. 

1  rat-tooth  forcep. 

1  anatomical  forcep. 

2  sharp  hooks. 
2  arterj^  forceps. 
1  pair  of  scissors. 

1  syringe  for  local  anaesthesia,  if  the  opera- 

tion is  not  to  be  performed  with  a^thyl 
chloride. 

2  brushes. 
Iodoform  gauze. 


Sterile  gauze. 
1  roller  bandage. 

1  roll  of  cotton  and  sublimate  tablets  are 
then  added. 

The  instruments  are  laid  upon  a  ster- 
ile hand  towel  with  sterile  forceps  and 
wrapped  in  it.  The  hand  towel,  which 
contains  everything  needed,  is  wrapped  in 
strong  paper  or  better  is  placed  in  a 
canvas  bag  {vide  Fig.  49) . 


(&)  In  case  of  major  operations  (herniotomy,  sequestrotomy ) ,  it 
is  well  for  the  surgeon  to  mentally  review  the  instruments,  so  that  none 
will  be  forgotten. 


Fig.  49. — Canvas  Bag  for  Caurying  Supplies  Which  May  Be  Used  in  Private  Practice. 

Bag  open. 

The  following  are  necessary  for  operations  upon  soft  parts: 


3  knives  (covered  with  cotton  or  lying 

in  a  frame). 
2  anatomical  forceps. 
2  rat-tooth  forceps. 
]   pair  of  straight  scissors. 
1   pair  of  curved  .scissors. 
10  arfery  forc(!ps. 

1  grooved  director. 

2  sharp  hooks. 


2  blunt  hooks. 
1  aneurysm  needle. 
1  box  filled  with  needles. 
1  needle  holder. 
1   nail  cleaner. 

Drainage  tubes  of  different  sizes. 
1  syringe  (for  local  an;esthesia,  morpIiinCf 
or  campTiorated  oil). 


ASEPSIS  AND  THE   ASEPTIC   OPERATION   IN   PRIVATE   PRACTICE       ,81 


The  following  slioukl  be  added  for  a  tracheotomy 


1  sharp  hook. 

1  Bosescher  retractor. 


1  sharp  spoon. 

1  Luer  bone-cutting  forcep. 

1  bone  scissors. 

5  wire  saws. 

1  kej^hole  saw. 


2  silver  canula>  of  different  sizes  provided 

with  tapes. 

Or  for  an  operation  upon  bone : 

3  bone  knives. 

1  periosteal  elevator. 

2  chisels. 
1   mallet. 

1  Esmarch  constrictor  or  rubber  tubing. 

For  bone  suture : 

1    drill  and  aluminum  -  bronze 
wire. 


For  amputation : 

1  amputation  knife. 
1    amputation   saw    (or   only 
wire  saws). 

When  the  instruments 
are  thoroughly  sterilized 
the  tray  is  taken  out  of 
the  instrument  boiler  and 
is    placed    upon    a    large 

sterilized  towel.     The  tray  is  then  wrapped  in  the  towel  and  the  follow- 
ing are  laid  on  top  : 

Things  required  for  anaesthesia — 
1  roll  of  iodoform   gauze   wrapped   in   a 

sterile  hand  towel. 
6  pairs  of  rubber  gloves  wrapped  in  gauze. 
1  bag  containing  6  bristle  brushes. 
1  razor. 

1  bottle  of  sublimate  tablets. 
1  jar  of  silk. 

1  jar  of  catgut. 

2  bars  of  good  alkaline  soap. 
1  bottle  of  cocaine  tablets. 


Fig.  50. — Hag  Closed. 


1  Iwttle   of  morphine   tablets  and   cara- 
])horated  oil. 

1  bottle  of  70-80  per  cent  alcohol   (250 

c.c). 
Some  rolls  of  gauze  and  roller  bandages, 
which  are  wrapped  in  a  sterile  towel. 

2  operating  gowns. 

Operating  and  hand  towels  should  also  be 
added. 


The  package  is  then  placed  in  a  tin-lined  canvas  bag,  which  may  be 
easily  sterilized  in  a  steam  sterilizer.  The  canvas  bag  is  fastened  by 
straps. 

One  or  two  packages  of  gauze,  depending  upon  their  size,  are  put  in 
another  canvas  bag. 

Another  bag  is  often  required  for  the  sheets  and  linen  used  in  major 
operations. 


82  ASEPTIC   TECHNIC 

Plaster  of  Paris  bandages  (also  alum  powder)  should  ho.  enrried  in 
tin  boxes  in  which  they  are  kept. 

Papier-mache  splints  may  be  carried  under  the  straps  of  one  of  the 
canvas  bags. 

If  a  number  of  operations  are  to  be  performed,  it  is  well  to  take 
an  instrument  boiler  along. 

When  an  operation  is  to  be  performed  in  a  honse,  that  room  should 
be  selected  which  has  the  best  light  and  is  used  the  least,  as  the  danger 
of  air  infection  is  thus  reduced.  The  conditions  in  a  sleeping  room  are 
unfavorable,  for  the  air  is  contaminated  with  dust  and,  besides,  it  is  dif- 
ficult, very  often  impossible,  to  perform  operations  in  bed.  Only  the 
most  insignificant  operations  should  be  attempted  in  this  way. 

Only  those  things  should  be  removed  which  interfere  with  the  opera- 
tion. The  taking  down  of  pictuies  and  curtains,  cleaning  the  floor,  etc., 
raises  so  nuich  dust  that  at  least  a  day  should  intervene  before  the  opera- 
tion is  performed. 

An  extension  table  (or  two  small  tables  may  be  placed  end  to  end) 
should  be  placed  near  a  window  or  under  a  chandelier,  and  covered  with 
several  blankets,  the  head  of  which  is  elevated  by  a  cushion  or  roll.  A 
rubber  sheet  should  be  placed  over  the  blankets  to  protect  them  from  the 
wet.  A  large,  fresh  sheet  should  be  spread  over  the  rubber  sheet,  and  the 
improvised  operating  table  is  then  complete.  While  the  operating  table 
is  being  prepared,  water  should  be  boiled  in  a  number  of  large  kettles. 
Four  or,  better,  six  washbowls  should  be  cleaned  wdth  green  soap  and 
rinsed  with  hot  water. 

A  good-sized  table  (a  sewing  table  answers  the  purpose  very  well) 
covered  with  a  sterile  towel  should  be  placed  at  the  side  of  the  table 
where  the  operator  stands.  After  the  hands  have  been  sterilized,  the 
contents  of  the  tray  above  described  should  be  emptied  and  arranged 
upon  this  table.  The  surgeon  is  then  al)le  to  help  himself  to  instruments, 
gauze,  sutures,  and  ligatures,  all  of  wdiieh  should  be  covered  with  a  sterile 
towel  until  required. 

Freshly  washed  linen  sheets,  tablecloths,  and  hand  towels  may  be 
used  foi-  a  luuiiber  of  different  purposes.  If  time  permits,  they  should 
be  ironed  M'ith  a  h(/t  iron  just  before  being  used.  In  this  way  the  sterile 
sheets  and  towels  may  be  saved  and  used  for  sterilizing  the  hands  and 
drying  and  protecting  the  field  of  opei-ati(m. 

AVashbowls  containing  alcohol,  sublimate  solution,  and  hot  water 
should  be  made  ready.  Water  cans  and  pitchers  filled  with  sterile  water 
should  be  kept  in  readiness. 

An  attendant,  a  nurse,  and  a  physician  are  required  in  an  operation 
perfoi-med  without  general  ana'sthesia.  When  all  ana'sthetic  is  given 
the  surgeon  should  have  another  colleague  or  an  assistant,  who  merely 


ASEPSIS  AND  THE   ASEPTIC   OPERATION    IN   PRIVATE   PRACTICE       S3 

holds  tlie  retractors  placed  by  the  operator  or  hands  insti'uiiients,  a  nurse, 
and  an  attendant  to  pour  water,  prepare  sublimate  solution,  and  hold 
basins. 

All  the  rules  of  asepsis  should  be  rigidly  observed.  Long  exposure 
of  wound  surfaces  and  touching  them  with  the  fingers  are  followed  by 
infection  more  frequently  than  is  the  ease  when  the  operation  is  per- 
formed in  a  regular  operating  room.  For  this  reason  the  operation 
should  be  performed  rapidly  but  thoroughly,  and  rul)ber  gloves  should 
alvvnys  be  worn.  It  should  also  be  borne  in  mind  that  the  conditions  for 
caring  for  the  wound  are  unfavorable;  therefore  the  sutures  should  be 
placed  far  apart,  and  whenever  the  tissues  have  been  lacerated  or  have 
been  touched  by  the  fingers,  an  iodoform  tampon  or  gutta  pereha  drain 
should  be  inserted. 

It  may  be  readily  understood  why  only  a  limited  number  of  opera- 
tions can  be  performed  with  safety  outside  of  the  hospital.  The  only 
aseptic  operations  which  should  be  undertaken  are  those  which  may  be 
rapidly  performed.  Operations  upon  inflammatory  processes  are  par- 
ticularly adapted  for  this  work.  Long  and  dilifieult  operations  should 
be  performed  in  the  patient's  home  only  W'hen  absolutely  necessary 
(e.  g.  amputation  of  thigh,  disarticulation  for  crushing  injury,  laparot- 
omy for  ileus).  [AVith  a  complete  emergency  outfit  and  well-trained 
assistants,  almost  as  satisfactory  aseptic  work  can  be  done  in  a  private 
house  as  in  a  hospital.] 

All  the  instruments  and  dressings  required  for  any  emergency  opera- 
tion may  be  easily  carried  in  two  medium-sized  traveling  bags.  The 
Bevan  emergency  bag  contains  the  following: 

1  emergency  bag  containing —  1  dozen  assorted  uterine  needles. 

1  amputating  knife  for  hip  and  thigh.  1  dozen  assorted  surgeons'  needles. 

1  amputating  knife  for  leg  and  arm.  1  hypodermic  syringe  and  tablets  in  an 
6  minor  operating  knives.                                              alumimmi  case. 

1  Enunett's  uterine  needle  holder.  1  set  of  Murphy's  l)uttons. 

12  Tait's  artery  forceps.  1  Knight's  stethoscope. 

1  pair  Collin's  retractors.  1  razor  strop. 

2  plated  probes.  1  4-oz.  metal-casea  hot  tie  for  alcohol. 
2  grooved  directors.  h  pound  of  ether. 

1  pair  straight  scissors.  1  bottle  of  sublimate  tablets. 

1  pair  curved  scissors.  1  coil  silkworm  gut. 

1  pair  strong  scissors,  6  inches.  1  hard  rubber  iodoform  duster. 

1  pair  Liston's  bone  forceps.  1   16-in.  telescope  case  containing: 

1  pair  curved  lithotomy  forceps.  6  plaster  of  Paris  bandages  (3  in.  by  6 
1  bone  curette.  yards). 

1  set  Brainard's  bone  drills.  1  can  of  sublimate  gauze. 

1  thermometer.  1  can  borated  gauze. 

1  metal  case  for  2  amputating  knives.  J  pound  of  absorbent  cotton. 

1  metal  case  for  8  smaller  knives.  h  dozen   gauze   bandages    (2   in.   by    10 
1  razor  in  case.  yards). 

7 


34  ASEPTIC   TECHNIC 

^  dozen   cotton   bandages    (2   in.    by   8        2  Nekton's  catheters  (soft  rubl)er). 

vards).  ^  filiform  bougies. 

2  bottles  of  assorted  catgut.  2  Hunter's  wedges. 

1  bottle  kangaroo  tendons.  1  bottle  of  assorted  drainage  tubes. 

1   Bouchard's  sjT^hon  syringe.  1  Esmarch's  bandage, 

l^-ounce  hard  rubber  syringe.  1   8-oz.   metal-cased    bottle    for    chloro- 

1  papier  mache  catheter  case.  form. 

6  dressino-  splints.  1  Esmarch's  chloroform  inhaler. 

2  plated  male  catheters.  3  duck  rolls  for  instruments. 
1   Buck's  lithotomy  staff.  1  Esmarch's  tongue  forceps. 

1  Rongeur  forceps  with  spring.  i  dozen   flannel   bandages    (4   in.    by   8 

1  pair  Ferguson's  bone-holding  forceps.  yards). 

1  lead  mallet.  2  brass  pidleys. 

1  Van  Buren's  bone  chisel.  3  dozen  safety  pins. 

1  Van  Buren's  bone  gouge.  1  pure  rubber  bandage  (2i-in.). 

1  mastoid  chisel.  2  rolls  adhesive  plaster  (1  and  'I^-in.). 

1  Gait's  trephine.  6  sterihzed  laparotomy  pads. 

1  metacarpal  saw  (movable).  8  sterilized  towels. 

1  Kocher's  director.  1  can  of  iodoform  gauze  (10  per  cent). 

1  Sayre's  periosteotome.  20  tubes  of  sterilized  silk. 

2  aneurysm  needles  (metal  handled).  Needles  for  intestinal  sutures. 

3  hard  rubber  trachea  tubes.  2  aprons. 

2  mouse  tooth  forcjps  (spring).  1  nail  brush. 

1  Volkmann's  curette. 

Literature. — v.  Bergmann.  Zur  Sublimatfrage.  Therap.  Monatshefte,  February, 
1887,  p.  41.—Borchardt.  Die  Desinfektion  unserer  Verbandstoffe.  Archiv  f.  klinische 
Chirurgie,  Bd.  63,  1902,  p.  516. — Brunner.  Weitere  Versuche  iiber  Katgutsterihsation. 
Beitr.  z.  klin.  Chirurgie,  Bd.  7,  1891,  p.  447. — Clatiditis.  Eine  neue  Methode  zur  Sterili- 
sation der  Seidenkatheter.  Zentralblatt  fiir  Chirurgie,  1902,  p.  46.5; — ^Eine  Methode 
zur  Sterilisierung  vmd  zur  sterilen  Aufhebung  des  Katgut.  Deutsche  Zeitschrift  fiir 
Chirurgie,  Bd.  64,  1902,  p.  489; — Erfahrungen  iiber  Jodkatgut.  Ebenda,  Bd.  69, 
1903,  p.  462. — Cleves-Symmes.  Untersuchungen  iiber  die  aus  der  Luft  sich  absetzenden 
Keime.  Arbeiten  aus  der  v.  Bergmannschen  Klinik,  Part  6,  1892.- — Elsberg.  Ein 
neues  und  einfaches  Verfahren  der  Katgutsterihsation.  Zentralbl.  fiir  Chir.,  1900, 
p.  537. — Friedrich.  Das  Verhiiltnis  der  experimentellen  Bakteriologie  zur  Chirurgie. 
Leipzig,  1897. — Greife.  Renntiersehnenfiiden  als  Naht-  und  Ligaturmaterial  an  Stelle 
des  Katguts.  Miinch.  med.  Wochenschr.,  1901,  p.  1005. — Haegler.  Hiindereinigung. 
Basel,  1900; — -Ueber  Ligatureiterungen.  Chir.-Kongr.  Verhandl.,  1901,  II,  p.  258; — 
Wundverbandmittel  in  Kochers  Enzyklop;ulie.^//erman.  Ueber  das  Sterilisieren 
der  Seidenkatheter.  Zentralbl.  f.  Chir.,  1901,  p.  63. — Hofmeister.  Ueber  Ka< gut- 
sterilisation.  Beitr.  z.  klin.  Chir.,  Bd.  15  and  16,  1896. — Koch.  Untersuchungen 
iil)er  die  Aetiologie  der  Wumlinfektionskrankheitcn,  1878. — Kochcr.  Chirurgische 
Operationslehre.  Jena,  1902. — Kanig.  Asei)(ik  der  Hiiiule?  Ojierationen  ohne 
direkte  Beriihrung  der  Wunde  mit  Finger  u.  Hand.  Zentrall)l.  f.  Chir.,  1900,  No.  36. 
— Fritz  Konig.  Das  neue  Operationshaus  in  Altona.  Archiv  fiir  klin.  Chirurgie, 
Bd.  70,  i;)()3,  p.  1078. — Martina.  Die  Katgutsterihsation  nach  Claudius.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  70,  1903,  p.  140. — v.  Mikulicz.  LTeber  die  jiingsten  Bestrebungen, 
die  aseptische  Wundbehandlung  zu  verbessern.  Chir.-Kongr.  Verhandl.,  1898,  I, 
J).  8;  im  Anschlusse  daran:  Landerer,  Perthes,  Doderlein,  und  Diskussion. — Minervini. 
Zur  Katgutfragc!.  Deutsche  Zeitschrift  f.  Chir.,  Bd.  53,4900,  p.  \.—Neuher.  Zur 
antisept.    \\  imdbehandlung.     Chir.-Kongr.    Verhandl.,    18!)2,    II,    p.    76. — liosenbach. 


ASEPSIS   AND   THE    ASEPTIC    OPEllATKJ.X    L\    PRI\Ali:    I'RAC'llLE       85 

Mikroorganismen  bei  den  Wundinfektionskrankheiten  ties  Mensehen,  1884. — Sarwcy. 
Bakteriol.  Untersuch.  liber  Handedesinfektion.  Berlin,  I'.tOo. — Said.  Ein  neuer 
Versuch  zur  Sterilisation  des  Katgut.  Arch,  fiir  klin.  Chir.,  lid.  52,  1806,  p.  'J8. — 
Schimmelbusch.  Die  Durchfiihrung  der  Aseptik  in  der  v.  Bergmannschen  Klinik. 
Arch,  fiir  klin.  Chirurgie,  Bd.  42,  1891,  p.  123; — Anleitung  zur  aseptischen  AVund- 
behandl.  Berlin,  1893,  2d  edition. — Sittler.  Die  Sterilisation  elastischer  Katheter. 
Zeiitralbl.  f.  Bakteriologie,  Bd.  38,  1905,  p.  752. — Witzcl.  Chirurgische  Hj^giene, 
Aseptik  u.  Antiseptik.     Die  deutsche  Klinik,  Bd.  8,  p   577. 


III.      GENERAL    AND    LOCAL   ANAESTHESIA 

GENERAL    ANAESTHESIA 

Since  the  discovery  of  their  angesthetic 'properties  ether  and  chloro- 
form have  contributed  immeasurably  to  the  advancement  of  surgery,  and 
are  to-day  the  most  important  general  aneesthetics. 

The  anaesthetic  properties  of  ether  were  discovered  first.  An  Ameri- 
can, Crawford  Long,  performed  an  operation  under  ether  anaesthesia  as 
early  as  1842.  Its  anaesthetic  properties  were  rediscovered  by  the  chem- 
ist Jackson,  and  were  employed  by  a  dentist,  Morton,  in  extracting  a 
tooth;  both  lived  in  Boston,  the  work  being  done  in  1846.  Surgeons 
soon  began  to  use  ether  (Warren  in  Boston,  Liston  in  London,  Mal- 
gaigne  in  Paris,  and  Dieffenbach  in  Berlin,  1847). 

Chloroform  anj^psthesia  was  discovered  by  an  Edinburgh  obstetrician 
(Simpson).  In  1847  he  delivered  a  patient  under  chloroform  after  ex- 
perimenting for  some  time  and  comparing  the  action  of  chloroform  with 
that  of  ether.  He  soon  recommended  its  use,  after  having  employed  it 
in  a  number  of  cases. 

Like  all  other  annesthetics,  ether  and  chloroform  are  poisonous.  Their 
property  of  rendering  patients  unconscious  and  insensitive  to  pain  after 
the  inhalation  of  certain  amounts  is  a  blessing  to  the  patient  and  a 
great  help  to  the  surgeon.  In  excess  and  in  susceptible  people  they  may 
cause  death  or  produce  lesions  which  eventually  may  end  fatally.  There- 
fore they  must  be  used  with  the  greatest  caution. 

A  physician  should  be  intrusted  with  the  administration  of  either 
anaesthetic.  Attention,  practice,  and  experience,  combined  with  coolness 
and  self-control  in  emergencies,  are  required  of  an  anaesthetist,  who 
should  meet  rapidly  and  effectively  any  emergency  which  may  arise. 


CHAPTER    I 

CTTT.OI{( )r'V>K M    AN.IOSTITKST A 

Physical  Properties  of  and  Tests  for  Chloroform: — Chloroform,  CTICI3, 
formyltrichloride,  trichlormethane,  is  a  clear,  colorless,  volatile  fluid  with 
86 


CHLOROFORM   ANAESTHESIA  87 

a  peculiar  aroinatic  odoi-  and  swcd  l)iiniiiiu  tastf.  It  l)(»ils  at  14'J'  F. 
It  is  docoiiiposed  by  dayliiiht  and  air  into  iiydrocliloric  acid,  chlorine,  free 
formic  acid,  phosgen,  etc.,  and  sliould  therefore  be  kept  in  dark  colored, 
tightly  closed  bottles.  By  the  addition  of  one  per  cent  absolute  alcohol 
the  decomposition  of  chloroform  may  be  prevented. 

Unpleasant  symptoms  have  followed  the  use  of  impure  chloroform; 
death  has  been  produced  by  its  decomposition  and  substitution  products. 
Only  reliable,  pure  preparations  should  therefore  be  used  for  ana'sthesia. 
[In  America  Squibb 's  chloroform,  especially  prepared  for  ana'sthcsia,  is 
generally  preferred.  It  comes  in  small  stained  glass  bottles,  which  may 
be  conveniently  used  for  dropping  the  chloroform.  Although  a  number 
of  manufacturers  have  placed  their  chloroform  upon  the  market,  Squibb 's 
is  still  generally  employed.] 

Ilepp's  smelling  test  may  be  employed  to  determine  whether  chloro- 
form is  pure  or  not.  It  is  used  in  the  following  way :  Some  chloroform  is 
dropped  upon  white  filter  paper  and  allowed  to  evaporate.  If  the 
chloroform  is  pure  the  paper  has  no  odor;  if  impure,  a  penetrating, 
rancid  odor  remains,  which  is  produced  by  the  decomposition  products. 

The  Action  of  Chloroform  Vapor  when  Inhaled. — Inhaled  chloro- 
form vapors  pass  into  the  blood  through  the  alveoli  of  the  lung,  and  are 
then  carried  to  all  the  organs,  including  the  central  nervous  system. 
The  paralysis  of  the  nerve  centers  begins  in  the  great  lobes  of  the  brain, 
then  attacks  the  cerebellum,  and  finally  the  spinal  cord,  sensation  being 
lost  before  motion.  The  centers  in  the  medulla  retain  their  function  the 
longest ;  if  these  are  paralyzed  death  occurs. 

Chloroform  in  large  amounts  or  with  susceptible  people  paralyzes  the 
ganglia  situated  within  the  heart  which  control  the  heart  beat,  and  is  toxic 
for  heart  muscle  itself.  A  fall  of  blood  pressure  follows  the  paralysis 
of  the  vaso-motor  center,  and  the  heart  has  to  perform  an  excessive 
amount  of  work  and  becomes  exhausted  (Kappeler).  The  direct  action 
of  chloroform  upon  the  nasal  and  laryngeal  mucous  membrane  may  cause 
a  reflex  respiratory  paralysis  and  influence  the  heart  beat  by  irritation 
of  the  trigeminal  branches  supplying  the  nasal  mucous  membrane,  and 
of  the  superior  laryngeal  nerve,  supplying  the  laryngeal  raucous  mem- 
brane, and  of  the  vagus. 

Like  any  other  anaesthetic,  chloroform  passes  into  the  blood  of  the 
foetus  and  into  the  milk  of  the  nursing  mother. 

Chloroform  is  excreted  by  the  lungs,  the  skin,  and  the  kidneys. 

It  produces  a  transitory  fatty  degeneration  of  the  myocardium, 
liver,  and  kidneys.  These  fatty  changes  may  become  more  extensive  and 
finally  cause  death,  especially  if  the  organs  were  previously  diseased. 

Preparation  of  Patient  for  General  Ansesthesia. — Every  patient  should 
receive  special  preparation  for  an  anaesthetic. 


88  GENERAL   AND   LOCAL   ANESTHESIA 

Washing-  the  mouth  aud  ck^auiug  the  teeth  reduce  the  dangers  of 
aspiration  pneumonia. 

If  possible  the  patient's  stomach  should  be  empty.  This  prevents 
the  accidents  resulting  from  vomiting,  and  lessens  the  distress  and  vomit- 
ing following  the  anaesthesia.  Patients  should  not  be  allowed  to  take 
food  for  six  hours  before  the  operation,  and  if  in  an  emergency  an 
anaesthetic  must  be  given  shortly  after  meal  time,  the  stomach  contents 
should  be  removed  by  a  stomach  tube. 

Tight  clothing,  corsets,  abdominal  binders,  and  collars  should  be  re- 
moved to  prevent  interference  with  respiration.  The  shirt  should  be 
left  open  at  the  neck,  and  foreign  bodies  (artificial  teeth,  tobacco,  and 
candies)  should  be  removed  from  the  mouth. 

[IMagaw,  in  a  review  of  over  fourteen  thousand  ansesthesias  induced 
in  the  Mayo  clinic  at  Rochester,  Minn.,  gives  some  very  practical  sug- 
gestions regarding  the  administration  of  an  anix'stlietie.  She  employs 
almost  exclusively  the  "  open  or  drop  method,"  and  prefers  ether  to 
chloroform.     She  describes  the  method  as  follows : 

"  Patients  usually  walk  into  the  operating  room  and  mount  the  table 
with  assistance.  All  foreign  bodies,  such  as  artificial  teeth,  chewing 
gum,  etc.,  are  removed.  The  hands  are  fastened  loosely  across  the  chest 
with  a  wide  gauze  bandage,  to  prevent  the  arms  falling  over  the  sharp 
edges  of  the  table,  an  accident  which  often  causes  musculospiral  paraly- 
sis. A  pad  of  moistened  cotton  is  placed  over  the  eyes  to  protect  them 
from  the  anesthetic.  If,  during  the  course  of  the  administration,  some 
of  the  anaesthetic  should  fall  in  the  eye,  drop  a  few  drops  of  castor  oil 
into  the  conjunctival  sac  to  prevent  the  conjunctivitis  that  would  other- 
wise follow. 

"  It  is  a  mistake  to  think  that  the  same  elevation  of  the  head  will 
do  for  all  patients.  The  anaesthetist  should  elevate  the  chin  to  such  a 
position  as  not  to  bend  the  neck  too  far  back  or  approximate  the  chin 
too  near  the  sternum.  Proper  elevation  of  the  head  will  relax  all  tis- 
sues of  the  neck  and  give  more  freedom  in  breathing.  This  also  can 
be  said  of  the  jaw.  Holding  the  jaw  forward  and  keeping  it  in  position, 
so  that  the  patient  gets  the  greatest  amount  of  air  possible,  is  an  impor- 
tant feature  in  giving  an  anaesthetic.  While  too  much  stress  cannot  be 
laid  on  this  necessary  requisite  in  giving  an  anaesthetic,  all  jaws  cannot 
be  handled  in  the  same  manner.  When  a  patient  has  removed  a  double 
set  of  false  teeth,  the  tongue  will  often  cleave  to  the  roof  of  the  mouth 
during  the  administration,  and  raising  the  jaws  sets  the  gums  so  firmly 
together  that  most  of  the  air  is  shut  out,  and  this  may  not  be  noticed 
until  the  patient  is  cyanotic.  We  have  found  in  this  class  of  eases  that 
if  the  jaw  is  held  but  slightly  up  and  forward,  and  the  thumb  at  the 
same  time  inserted  between  the  gums,  thereby  holding  the  tongue  down. 


CHLOROFORM   ANAESTHESIA  89 

faulty  respiration  will  be  corrected  at  once  and  color  restored.  This 
is  one  of  the  instances  where  holding  up  of  the  jaw  too  firmly  may  be 
overdone. 

"  All  patients  have  been  anesthetized  on  the  operating  table  in  the 
operating  room,  and  the  preparation  of  the  patient  was  going  on  at  the 
same  time.  Experience  has  taught  us  that  preparation  of  the  patient 
while  going  under  the  anaesthetic  is  one  of  the  important  factors  in  pro- 
ducing a  rapid  surgical  narcosis,  for  it  diverts  his  attention  and  much 
less  anaesthetic  is  required.  It  matters  not  in  what  position  the  patient 
must  be  for  operation,  we  fix  hira  accordingly,  and  the  preparation  is 
begun  at  the  same  time  as  the  ana?sthetic,  and  we  feel  certain  that  this 
procedure  enables  us  to  hasten  narcosis. 

' '  In  the  Trendelenburg  position,  where  the  preparation  is  in  progress 
during  the  administration  of  the  anesthetic,  the  deep  respiration,  etc., 
empties  the  pelvis,  so  that  by  the  time  the  operation  is  started  the  small 
bowel  will  be  found  in  the  upper  abdomen  and  out  of  the  way,  and  may 
be  packed  off.  We  have  found  this  practice  more  helpful  to  the  surgeon 
than  placing  the  patient  in  position  after  the  completion  of  narcosis. 

"  In  giving  an  anaesthetic  for  this  class  of  surgery,  the  skill  and 
patience  of  the  anaesthetist  is  tried  to  the  extreme,  and  the  patient  nnist 
be  anesthetized,  but  not  too  profoundly.  Patients  having  an  acute  peri- 
tonitis, as  is  so  often  found  in  this  class  of  cases,  require  a  much  larger 
amount  of  anesthetic  to  produce  relaxation  of  abdominal  muscles.  AYhen 
the  patient  is  prepared  during  the  administration  of  an  anaesthetic,  there 
is  no  time  lost,  the  surgeon  and  his  assistant  being  ready  by  the  time 
the  patient  is  surgically  anesthetized.  Another  important  reason  for 
anesthetizing  the  patient  on  the  operating  table  is  that  in  lifting  and 
shifting  a  patient  about  he  is  apt  to  regain  consciousness,  with  vomit- 
ing, etc.,  and  the  anaesthetist  cannot  be  positive  of  the  condition  of  his 
patient.  Should  ether  produce  difficult  breathing,  profuse  secretion  of 
mucus  or  cough,  lift  the  mask  from  the  face,  allow  a  liberal  amount  of 
air,  and  then  continue  with  ether.  In  giving  plenty  of  air  when  needed 
and  less  anesthetic,  we  have  found  little  use  for  an  oxygen  tank,  a  loaded 
hypodermic  syringe,  or  tongue  forceps.  It  is  far  better  for  the  anes- 
thetist to  become  skillful  in  watching  for  symptoms  and  preventing  them 
than  to  become  proficient  in  the  use  of  the  three  articles  above  men- 
tioned. An  acute  cold  is  a  contraindication  to  any  anesthetic,  but  as 
soon  as  a  cold  becomes  chronic  there  is  not  nnich  danger  from  etheriza- 
tion, and  instead  of  operating  during  an  acute  cold  and  giving  chloro- 
form (unless  in  an  emergency),  we  wait  a  few  days  until  tlie  acute 
attack  has  passed,  and  then  they  are  as  good  subjects  for  ether  as  for 
any  other  anesthetic.  Chronic  bronchitis  is  often  improved  by  an 
anesthetic."] 


90  GENERAL   AND   LOCAL   ANESTHESIA 

The  anaesthetist  should  gain  and  retain  the  confidence  of  the  patient, 
who  should  not  be  permitted  to  see  the  instruments  or  any  blood-stained 
sheets  or  dressings.  Patients  frequently  become  excited  and  frightened 
upon  entering  the  operating  room,  and  for  this  reason  it  is  the  custom  in 
a  number  of  clinics  to  begin  the  anaesthesia  in  a  small  room  immediately 
adjacent  to  it. 

Position  in  which  Patient  should  be  Placed  for  General  Anaesthesia. — 
Before  the  administration  of  the  anaesthetic  is  begun  tlie  patient  should 
be  placed  in  a  comfortable  horizontal  position;  the  head,  which  should 
neither  be  extended  nor  markedly  flexed,  lying  on  a  small  roll  or  pillow. 
The  head  and  trunk  of  weak,  ana?mic  patients  should  never  be  elevated, 
especially  if  a  major  operation  is  to  be  performed.  In  these  cases  the 
head  and  trunk  should  be  lowered,  as  in  this  way  the  dangerous  effects 
of  cerebral  anaemia  may  be  avoided.  If  the  position  is  comfortable,  the 
patient  should  be  asked  to  close  his  eyes,  to  breathe  naturally,  and  to 
avoid  swallowing  saliva.  In  order  to  distract  the  attention  of  the  patient 
he  may  be  asked  to  count. 

The  Different  Stages  of  General  Anaesthesia. — Chloroform  angesthesia, 
like  all  general  anasthesias,  passes  through  four  stages: 

1.  Initial  stage,  3.  Stage  of  deep  anaesthesia. 

2.  Stage  of  excitement.  4.  Stage  of  awakening. 

1.  After  the  first  few  inspirations  most  patients  begin  to  hold  their 
breath  and  swallow  air.  The  sweet  taste  and  odor  of  chloroform  vapor 
is  disgusting  to  many,  especially  to  children  and  patients  who  have  been 
ana'sthetized  a  number  of  times.  During  this  stage  patients  frequently 
experience  a  sensation  of  suffocation  and,  crying  for  air,  tear  the  mask 
from  the  face.  Soon  spots  appear  before  the  eyes,  the  patient  becomes 
dizzy  and  has  unpleasant,  often  terrifying  dreams,  the  ears  ring  and  the 
heart  pounds.  The  face  becomes  redderted,  the  patient  talks  incohe- 
rently, alternately  laughs  and  cries  and  acts  like  a  drunken  man.  Con- 
sciousness and  sensation  are  gradually  reduced,  and  then  rapidly  lost. 
The  salivary  secretion  is  increased,  the  pulse  is  rapid  and  full,  the  res- 
piration rapid  but  deep ;  the  pupils  are  dilated  but  react  to  light,  and 
when  the  eyelids  are  raised  and  the  cornea  touched  a  wink  may  be 
elicited.  The  reflex  irritability  is  still  considerably  increased,  and  a 
painful  examination  or  sometimes  too  early  sterilization  of  the  field  of 
operation  may  excite  violent  and  often  dangerous  struggles. 

2.  The  stage  of  excitement  is  the  more  pronounced  the  more  un- 
evenly and  rapidly  the  anaesthetic  is  given.  Children  do  not  pass  through 
this  stage;  women  fi^efjuently  do  not.  It  is  rarely  absent  in  men,  being 
most  marked  in  the  strong  and  vigorous  and  in  alcoholics.  It  begins  with 
contraction  of  the  muscles  of  llie  liui.k  which  lasts  but  a  short  time,  sud- 


CHLOROFORM    AX/ESTIIESIA  91 

den  extension  of  the  head  and  extremities,  and  it  may  end  quickly.  If 
the  stage  is  more  pronounced  the  patient  acts  as  though  insane,  clutches 
the  angesthetizer,  flings  his  arms  about,  distorts  the  face,  tries  to  get  up 
or  throw  himself  from  the  tal)le.  Urine,  gas,  and  fa'ces  may  be  dis- 
charged by  the  contraction  of  the  abdominal  muscles.  The  patient  sings, 
shrieks,  and  moans,  expectorates  into  the  mask,  breathes  deeply  and  rap- 
idly or  may  hold  his  breath,  and  then  his  face  becomes  c3'anotic.  The 
jaws  are  closed  by  a  spasm  of  the  masseters,  the  eyes  are  rolled  about, 
the  pupils  are  slightly  dilated,  and  react  but  little  to  light. 

3.  After  a  few  minutes  the  contracted  muscles  become  relaxed,  the 
raised  hand  falls,  the  face  becomes  smooth,  and  the  stage  of  deep  anaes- 
thesia in  which  major  operations  may  be  performed  is  reached.  As  a  rule 
it  requires  about  ten  minutes  to  bring  the  patient  to  this  stage  of  anaes- 
thesia. Finally  the  masseters  relax,  the  jaw  and  the  tongue  drop  back- 
ward, and  the  patient  snores;  the  face  becomes  pale,  the  pupils  contract 
and  react  but  little  to  light.  The  reflexes  are  abolished,  and  if  the  cornea 
is  touched  there  is  no  reaction.  The  pulse  becomes  slow,  the  respirations 
regular  and  superficial. 

Chloroform  does  not  interfere  with  uterine  contractions,  but  stops 
the  contraction  of  voluntary  muscles  which  supplement  these.  It  is  ex- 
tensively employed  by  obstetricians. 

4.  Some  patients  recover  from  an  anaesthetic  more  rapidly  than  others, 
and  they  behave  difl:'erently.  Rolling  of  the  eyes  is  the  first  sign  of 
awakening.  As  a  rule,  children  after  crying  or  vomiting  fall  asleep 
again.  Adults  vomit,  then  become  excited  and  laugh  or  cry  (particularly 
alcoholics  and  hysterical  patients)  ;  some  experience  a  sensation  of  well- 
being,  following  the  excitement  of  the  operation.  ]\Iost  men  desire  to 
sleep  and  be  left  alone ;  they  are  irritable  and  complain  of  headache  and 
discomfort,  which  is  increased  by  pain  in  the  wound. 

The  operator  should  pay  as  much  attention  to  the  length  of  time  the 
anaesthetic  is  given  as  he  does  to  operative  technic,  asepsis,  and  the  con- 
trol of  haemorrhage.  On  an  average,  amesthesia  should  not  be  continued 
for  more  than  an  hour ;  even  in  the  most  difficult  cases  not  for  more  than 
two  hours.  The  shorter  the  anesthesia,  the  greater  the  chances  of  recov- 
ery from  major  operations. 

It  is  difficult  to  measure  the  amount  of  anasthetic  given  when  an 
ordinary  mask  is  used.  During  expiration,  especially  in  the  stage  of 
excitement,  the  chloroform  evaporates.  The  amount  can  be  measured 
only  when  an  apparatus  especially  constructed  for  the  purpose  is  used. 

The  administration  of  chloroform  is  an  art.  The  anasthetist  should 
devote  his  entire  attention  to  the  administration  of  the  anasthetic,  and 
should  pay  no  attention  whatever  to  the  operation.  If  the  operation  is 
upon  the  head  or  neck,  he  should  sterilize  his  hands,  put  on  a  sterde 


92 


GENERAL   AND   LOCAL   ANESTHESIA 


gown,  use  a  sterile  mask,  and  wrap  the  chloroform  bottle  in  sterile  gauze. 
He  should  note  the  appearance  and  color  of  the  face,  test  the  pupillary 
or  corneal  reflexes,  watch  the  breathing,  note  the  respiratory  movements 


Fig.   51. — The  Chloroform  Mask  of  Schimmelbusch.    .(From  Dumont.) 

of  the  abdominal  wall  and  take  the  pulse,  if  this  is  not  delegated  to  a 
colleague.  Rather  intrust  the  ansesthetie  to  an  experienced  nurse  than 
to  an  inexperienced  physician.     Another  physician  besides  the  operator 

should  be  present  to  as- 
sist in  case  of  accident, 
and,  as  a  precaution,  to 
act  as  a  witness  if  accu- 
sations of  assault  or  theft 
should  be  made. 


Fig.  .52. — a,  IIeisteh'-^  Moi-rit  Cx\(;  (from  J)um()nt);  /),  Tino  Koenig-Roser  Mouth  Gag 

(from   J)urnont). 

Everything  that  may  Ix'  re<|uire(i  should  be  near  at  hand.  The  Schim- 
mell)usch  iiiaslc  is  usually  used  when  chlorofoi'in  is  administered.  It 
consists  (iT  a  wire  fi-aiiie  which  may  be  sterilized,  over  which  gauze  is 
fastened,  (/liloroform  is  kept  in  small  brown  bottJes.  Different  provi- 
sions  are   made    for  (li-()|)|)iii;4    it.     The   lleister,    Koenig-Roser,   or  the 


CHLOROFORM   ANESTHESIA 


93 


newer  P.  von  Brnns  mouth  gag  may  be  used.  Tongue  foreeps,  steel 
sponges,  a  towel,  and  a  basin  to  cateh  the  vomitus  should  be  provided. 

A  clean  handkerchief  may  be  used  instead  of  a  chloroform  mask.  It 
should  not  be  laid  directly  npoli  the  face,  for  the  chloroform  ma}'  burn 
the  skin,  even  if  vaseline  has  previously  been  applied.  A  stand-np  collar, 
buttoned  in  front  and  bent  into  an  oval,  may  be  placed  upon  the  face 
and  a  handkerchief  sju'ead  out  over  it. 

Apparatus  for  Determining  Amount  of  Chloroform  Administered,  etc. 
— The  different  apparatus  used  in  large  clinics  for  the  administration  of 
chloroform  have  some  advantages,  as  the 
amount  of  chloroform  can  be  accurately 
measured  and  the  amount  of  oxygen  given 
with  it  controlled,  and  thus  if  the  breathing 
is  deep,  the  danger  of  giving  too  much 
chloroform  is  reduced.  The  Junker  appa- 
ratus, improved  by  Kappeler  (Fig.  53),  is 
provided  with  a  rubber  bag,  and  by  pressing 
it  a  mixture  of  chloroform  and  air  is  sup- 
plied to  the  patient.  The  Wohlgemuth  and 
Rotli-Driiger  apparatus  are  too  large  for 
practical  purposes  and  are  expensive.  They 
supply  a  mixture  of  chloroform  and  oxygen, 
and  in  case  of  asphyxia  oxygen  alone  may 
be  given.  Any  apparatus  has  the  disadvan- 
tage that  the  ana?sthesia  is  induced  slowly ; 
often  it  does  not  pass  beyond  the  stage  of 
excitement  and  mnst  be  continued  with  the 
ordinary  mask. 

Dropping  of  Chloroform. — In  administer- 
ing chloroform  a  dry  mask  should  be  laid 
upon  the  face,  covering  the  mouth  and 
nose,  and  then  chloroform  should  be  slowly 
dropped  npon  it,  from  10  to  60  drops  be- 
ing given  in  a  minute,  depending  npon  the 
age  of  the  patient.  This  may  be  increased 
up  to  even  twice  the  amount,  until  the  stage 
of   excitement   begins.      A   saturated   mask 

should  never  be  nsed,  because  of  the  danger  of  induciug  a  violent  stage 
of  excitement  and  causing  reflex  cardiac  or  respiratory  paralysis.  This 
is  often  done,  even  by  experienced  anaesthetists.  If  the  patient  is  greatly 
excited  the  mask  should  be  removed  for  one,  two  or  more  minutes  to 
avoid  administering  too  much  when  he  begins  to  breathe  deeply.  After 
such  interruptions  the  anaesthesia  should  be  continued.    About  60  drops 


Fig.  53. — Jinki:u'.s  Aii'vitA- 
Tus  AS  Modified  by  Kap- 
peler.    (From  Dumont.) 


94  GENERAL   AND    LOCAL   ANESTHESIA 

should  be  given  in  a  minute  until  the  patient  is  relaxed.  An  expe- 
rienced anaesthetist  regulates  the  dropping  of  the  chloroform  by  intui- 
tion or  the  carotid  pulse.  If  the  pulse  is  ra[)id  one  drop  is  given  for 
every  two  to  three  beats;  if  slow,  one  drop  for  each  beat.  The  chloro- 
form bottle  should  be  held  near  the  mask,  so  that  if  the  patient  moves 
the  chloroform  will  not  be  dropped  upon  the  skin  or  in  the  eye.  The 
skin  has  been  burned,  and  corneal  opacities  have  been  caused  in  this 
way.  Such  results  may  be  avoided  if  the  chloroform  is  wiped  off  the 
skin  and  the  eye  irrigated  immediately  after  such  an  accident.  During 
the  stage  of  excitement  the  patient  should  not  be  forcibly  restrained, 
as  this  merely  increases  the  excitement,  and  fractures  and  dislocations 
may  be  produced. 

Different  Methods  of  Holding  the  Jaw  Forward. — If  in  deep  anaes- 
thesia the  breathing  becomes  stertorous  and  labored  the  jaw  should  be 
draAvn  forward,  and  in  adults,  as  a  rule,  it  should  be  held  in  this  posi- 
tion, for  as  the  jaw  drops  backward,  carrying  the  tongue  with  it,  the 
relaxed  epiglottis  is  pushed  downward,  closing  the  opening  of  the  larynx. 
In  pushing  the  jaw  forward  the  von  Esmarch-IIeiberg  method  may  be 
employed :  The  fiat  hand  is  placed  over  the  ear,  the  tips  of  the  index 
fingers  behind  the  angle  of  the  jaw  and  the  thumbs  upon  the  temporal 
or  frontal  regions,  and  the  jaw  is  then  gently  pushed  forward  by  the 
index  fingers  until  the  lower  teeth  project  beyond  the  upper.  The 
different  steps  in  this  method,  the  correct  and  false,  are  represented  in 
Figure  54,  a  and  h.  Pressure  should  not  be  made  upon  the  internal  jugu- 
lar vein,  and  too  much  force  should  not  be  used,  as  the  jaw  may  be  dis- 
located or  a  contusion  about  tlie  angle  of  the  jaw  produced.  If  the  pa- 
tient's head  is  turned  to  the  right,  the  jaw  may  be  held  in  this  way  by  the 
left  hand  alone,  and  the  right  hand  be  used  for  giving  the  anesthetic. 
If  this  does  not  suffice  to  overcome  the  embarrassment  of  respiration,  the 
mouth  should  l)e  opened  with  the  mouth  gag  and  the  tongue  drawn  for- 
ward. If  it  is  necessary  to  hold  the  tongue  forward  for  some  time,  it 
is  advisal)le  to  pass  a  heavy  silk  ligature  through  it;  in  this  way  the 
injuiy  produced  ])y  tongue  forceps  may  be  avoided. 

If  the  antesthetist  stands  in  fi'ont  of  the  patient  the  jaw  may  be 
drawn  forward  by  the  Kappeler  method  :  The  thumbs  Ix'ing  placed  upon 
the  maxillu'-beside  the  nose,  and  the  flexed  index  fingers  behind  the  angle 
of  the  ni;in<lil)lc,  jiiid  llic  jaw  drawn  foi'ward. 

Stage  of  Anaesthesia  Which  should  be  Maintained  During  an  Operation. 
— It  is  tlic  duty  oi'  tlie  ana'stlict ist  to  k('(>p  tlic  ])n1i('ut  in  the  ([uiet  stage 
of  anu'stlicsia,  permitting  hini  neither'  to  awake  nor  to  be  overcome  by 
a  fatal  j)aralysis  of  the  respii-atioii  or  of  the  heart.  The  character  of 
the  pulse  and  respiration,  the  color  of  the  f ace,  ^and  the  condition  of 
the  pu{)ii  indicate  the  condition  of  the  patient. 


■*?  (^ueiner  del.  Y903 


Fig.  54.^-PrSHixG  thk  Lower  Jaw  Fohward.     a,  Incorrect  method;  the  jaw  is  not  pushed 
far  enough  forward,  the  internal  jugular  vein  is  compressed;  b,  the  correct  method. 

95 


96  GENERAL  AND   LOCAL   ANESTHESIA 

To  test  the  pupillary  reflex  both  upper  lids  should  be  raised  by  the 
second  and  third  fingers,  after  they  have  been  tightly  closed  for  a  second. 
In  the  first  and  second  stages  of  aniesthesia  the  pupil  is  dilated  and  re- 
acts slowly,  because  of  irritation  of  the  cervical  sympathetic.  In  the 
beginning  of  the  third  stage  the  pupil  becomes  "contracted  but  reacts 
quickly.  As  the  anasthesia  becomes  deeper  the  pupil  becomes  narrower 
and  reacts  less  rapidly,  until  finally,  as  the  result  of  irritation  of  the 
oculomotor  nerve,  it  becomes  fixed  and  pinhead  in  size.  When  the  pupil 
is  in  this  condition  the  stage  of  deepest  permissible  anaesthesia  has  been 
reached.  Ana'sthesia  should  not  be  carried  to  this  so-called  normal  point, 
but  should  be  maintained  in  that  stage  in  which  the  pupils  are  contracted, 
but  react  to  light.  If  the  anassthesia  is  carried  beyond  the  normal  point, 
the  pupils  will  dilate,  because  of  paralysis  of  the  sphincter  iridis,  and  will 
not  react,  and  cardiac  and  respiratory  paralysis  will  rpiickly  occur.  It  is 
impossible  to  give  any  definite  rules  by  which  ana3sthesia  may  be  main- 
tained at  the  proper  stage.  Each  patient  behaves  differently;  some  re- 
quire a  long,  some  a  short  time,  to  reach  this  point.  (The  danger  zone 
varies,  Czempin.)  It  is  so  rapidly  reached  and  passed  by  many  that  it 
may  be  overlooked  by  the  ana?sthetist.  In  children  and  weak  adults 
two  to  four  drops  of  chloroform  in  a  minute  are  enough  to  maintain  deep 
anesthesia.  In  adults  about  twenty  drops  are-  required,  but  sixty  to 
eighty  drops  may  be  required,  especially  for  men. 

Interrupted  Anaesthesia. — It  is  most  difficult  to  give  an  interrupted 
anaesthesia,  as  is  often  required  in  operations  about  the  head  and  face, 
and  to  avoid  the  dangers  described  above.  Awakening  with  vomiting 
and  the  dangerous  stage  of  inactive  dilated  pupils  quickly  follow  each 
other,  if  the  anasthetist  is  not  skilled  and  attentive.  In  these  cases  the 
patient  should  be  slowly  anaesthetized  until  the  pupils  contract,  and  then 
the  mask  should  be  removed  so  as  to  expose  the  field  of  operation.  As 
soon  as  the  reflexes  return  and  the  pupils  dilate  again,  more  ana\sthetic 
should  be  given. 

The  disadvantages  of  this  interrupted  anaesthesia  may  be  avoided  if 
the  canula  devised  by  Salzer  is  employed.     This  bent  canula  (Fig.  55) 


Fig.  55. — .Sai.zkr's  Ciii-oiiofoum  Canula  to  Be  Inserted  into  the 
Mouth  in  Oi'euations  upon  the  Face  and  Mouth.  (From  the 
Clinic  f)f  von  Mikulicz.) 

is  iiiscijcd  into  tlie  moiitli  cavity  at  tlie  angle,  and  is  then  attached  to 
the  .Junker-Kappeler  ;ii)|)ai;itiis.  |A  riibl)ei-  catheter  or  piece  of  rubber 
tubing  may  be  passed  llii-ough  the  nose  into  the  nasopharynx,  and  the 
ana'sthetic  administered  through  it  after  being  attached  to  the  apparatus 


CHLOROFORM   ANESTHESIA  97 

above  mentioned.     It  is  much  simi)lor  jiiid   iiioic  coiixcnifiit   tluiu   tlie 
special  caniihi'  which  liavc  been  (Un-ised.  | 

Pupillary  and  Corneal  Reflexes. — The  testing'  of  pupillary  reflcxt-s  is 
unreliable  in  hysterical  patients,  as  frequently  the  pii])ils  do  not  con- 
tract. The  pupillary  reflex  is  also  unreliable  in  all  conditions  character- 
ized by  myosis,  such  as  morphinism,  nicotine  poisoning-,  locomotor  ataxia, 
paretic  dementia,  diseases  of  the  corpora  quadrigemina,  meningitis.  ]\Ior- 
phine  is  frequently  given  before  a  genci-al  ana'sthetic  is  administered, 
and  in  these  cases  it  should  be  remendjered  that  no  significance  whatever 
can  be  attached  to  the  pupillary  reflex.  [It  is  the  belief  of  the  editor 
that  too  much  significance  has  been  attached  to  both  the  pupillary  and 
corneal  reflex.  The  latter  is  unreliable  and  rc^sults  following  its  elici- 
tation  are  often  distressing;  as  severe  conjunctivitis  ma.y  follow  the  injury 
inflicted  on  the  corneal  epithelium.  It  is  nuich  more  essential  that  the 
anai'sthetist  note  carefully  the  respiration  and  the  color  of  the  patient. 
Cj^anosis  means  danger,  and  the  ana?sthetic  should  W'  withdrawn  when 
the  patient  becomes  dusky.  Any  interference  with  i'esi)ii'ation  should 
be  instantl.y  recognized  and 
relieved.] 

It  is  occasionally  neces- 
sary to  administer  an  an- 
aesthetic through  a  Ilahn 
or    Trendelenburg    tampon 

Canula.    The  apparatus  rep-         Fig-  56.— Chloroform  Apparatus  for  Admixister- 

,       ,  .  „.  r-n  1^'G    AN    Ax.ESTHETIC    THROUGH    A    TrACHEOTOMY 

resented     ni     Figure     o6,  ^ube.    (From  Dumont.) 

which   consists   of   a  metal 

funnel  and  a  tube,  may  be  used  for  this  purpose.     The  funnel  is  covei-tnl 

or  filled  with  gauze,  upon  which  the  anaesthetic  is  dropped  and  the  tul)e 

is  attached  to  the  canula. 

The  character  of  the  pulse  should  be  carefully  noted  during  the 
entire  anaesthesia,  as  it  indicates  dangerous  overexertion  of  tlie  heart 
and  is  a  good  index  as  to  the  general  condition  of  tiie  i)atient.  tlie  etfect 
of  the  ana'sthetic,  and  the  operation. 

After  Effects  of  Chloroform  Anaesthesia. — Thi'  aftei-  effects  of  chloro- 
form ana'Sthesia  vary  in  different  patients,  being  largely  dejiendent  upon 
the  amount  of  chloroform  used.  They  occur  most  freiiuently  after  long 
or  frequently  repeated  anaesthesias.  Nausea  and  vomiting  are  the  most 
constant,  as  the  gastric  mucous  membrane  is  irritated  by  the  saliva 
swallowed  at  the  beginning  of  the  ana-sthesia  and  by  the  chloroform  va- 
por. The  so-called  "  chloroform  distress  "  persists,  as  a  rule,  for  twenty- 
four  hours,  but  may  last  from  two  to  three  days  and  render  the  patient 
very  weak.  Icterus  frequently  follows  chloroform  anaesthesia  as  the 
result  of  changes  in  the  liver,  and  the  destruction  of  red  blood  corpus- 


98  GENERAL   AND   LOCAL   ANAESTHESIA 

cles.  The  stomach  symptoms  may  sometimes  be  preventiMl  if  a  towel 
moistened  with  vinegar  is  applied  to  the  nose  inmiediately  after  the 
patient  awakes  (Lewin).  Post-ami^sthetic  nausea  and  vomiting  may  be 
prevented  by  washing  out  the  stomach  with  Inkewarm  water  or  a  one 
or  two  per  cent  soda  solution,  and  by  withholding  food.  If  not  nauseated 
the  patient  may  be  given  some  nourishment  in  four  or  five  hours  after 
awakening.  It  is  best  to  begin  with  teaspoonfuls  of  tea,  warm  soup,  or 
red  wine.  Coffee  and  mineral  waters  should  be  avoided,  as  the  former 
causes  heartburn,  the  latter  incite  vomiting.  If  the  vomiting  continues 
for  some  time,  rectal  feeding  is  indicated  (milk  with  eggs;  in  case  of 
collapse,  warm  red  wine  with  cloves).  The  swallowing  of  air  frequently 
incites  vomiting.  A  small  dose  of  morphine  frequently  controls  the 
vomiting.  The  administration  of  favorite  articles  of  food  should  be 
discouraged. 

Patients,  as  a  rule,  do  not  sleep  the  night  following  the  operation. 
Nervous  irritability,  pain  in  the  wound,  unusual  positions  in  bed,  nau- 
sea, etc.,  are  the  usual  causes.  Weak  patients  should  be  given  morphine 
to  induce  sleep.  Hysterical  and  melancholic  patients  may  have  attacks 
of  mania;  the  nervous  symptoms  may  last  several  days. 

Post-Anaesthetic  Palsies. — The  so-called  post-ana  sthetic  palsies  are 
mostly  peripheral.  The  musculospiral  nerve  may  be  paralyzed  if  the 
arm  is  allowed  to  hang  over  the  sharp  edge  of  the  operating  table.  The 
nerves  of  the  brachial  plexus  may  be  pressed  upon  and  contiLsed  by  the 
clavicle  or  the  head  of  the  humerus  if  the  arm  is  strongly  abducted. 
These  palsies  may  last  for  some  time.  Central  paralysis,  the  result  of 
a  haemorrhage  into  the  brain  during  the  stage  of  excitement,  is  rare. 

If  the  joatient  does  not  recover  from  the  anaesthetic,  he  becomes  pro- 
gressively restless,  the  pulse  becomes  weak  and  fluttering,  the  vomit- 
ing becomes  uncontrollable,  the  urine  contains  albumin,  the  urinary  secre- 
tion diminishes  and  urannic  symptoms  develop,  and  death  from  collapse 
may  follow  in  from  one  to  three  days. 

If  the  post-mortem  examination  discloses  fatty  degeneration  of  heart 
muscle,  fatty  degeneration  and  necrosis  of  the  cells  of  the  kidney  and 
liver,  death  should  be  attributed  to  the  late  effects  of  chloroform.  It  is 
often  difficult,  however,  to  exclude  in  these  cases  other  causes  of  death, 
such  as  operative  shock  after  long  operations,  ana-mia  following  severe 
ha'morrhage,  and  acute  general  infections.  i 

Broncho-pneumonia  and  bronchitis  are  rarely  caused  by  chloroform, 
and  when  they  occur  should  be  i^egarded  as  produced  by  the  aspiration 
of  saliva  or  vomitus,  if  pulmonary  embolism  can  be  excluded.  Broncho- 
])neumonia  and  bronchitis  follow  (|uite  frequently  abdominal  operations 
in  which  pain  prevents  coughing.  They  also  follow  anaesthesias  admin- 
istered in  rooms  where  there  are  improtected  kerosene  or  gas  flames,  as 


ETHER   ANAESTHESIA  99 

the  chloroform  is  decomposed  into  phosgen  gas,  hj^drochloric  acid,  chlo- 
rine, and  other  bodies  which  irritate  the  hings.  A  peculiar  odor,  irrita- 
tion of  the  throat  of  the  patient  and  that  of  the  surgeon,  and  a  ha;^iuess 
about  the  operating  table  indicate  that  this  decomposition  is  occurring. 
If  this  happens,  the  windows  and  doors  slKnild  l)e  ()[)cni'd  iiimiediately. 


CHAPTER    II 

ETHER   ANiESTHESIA 

Physical  Properties  of  Ether. — Ether,  sulphuric  ether.  C^H,„0,  is  a 
clear,  diffusible,  colorless,  inflammable  fluid  with  a  peculiar  odor;  is  very 
volatile,  boils  at  95°  F.,  and  has  at  59°  F.  a  specific  gravity  varying  from 
0.720  to  0.722. 

Ether  should  be  kept  in  tightly  sealed  cans  or  brown  bottles  and  pro- 
tected from  the  light  and  air  in  order  to  prevent  decomposition.  Only 
pure  preparations  of  ether  should  be  used  for  anaesthesia.  Impure  ether, 
after  evaporation  in  a  watch  crystal,  leaves  a  residue  which  colors  blue 
litmus  paper  red. 

Differences  between  Chloroform  and  Ether  Anaesthesia. — Ether  vapor 
when  inhaled  has  nnieh  the  same  etf ect  as  that  of  chloroform ;  the  four 
following  differences,  however,  should  be  noted:  1.  Ether  has  less  effect 
upon  the  heart  than  chloroform,  and  there  is  less  danger  of  death  from 
cardiac  paralysis  when  ether  is  employed.  2.  Ether,  as  a  rule,  raises 
blood  pressure,  while  chloroform  lowers  it.  3.  Ether  has  a  wider  danger 
zone  than  chloroform — that  is,  the  difference  between  the  anaesthetic  and 
fatal  dose  of  ether  is  greater,  and  therefore  there  is  less  danger  of  sudden 
collapse  during  ether  anaesthesia.  4.  Ether  irritates  the  nuicous  mem- 
branes of  the  respiratory  passages,  especially  those  of  the  mouth,  nose, 
and  pharynx.  Lesions  of  the  lung  frecjuently  follow  its  use.  The 
changes  in  the  lung  may  be  due  to  the  aspiration  of  saliva,  the  secretion 
of  which  is  increased,  as  well  as  to  the  direct,  irritating  action  of  the 
ether  vapor.  This  is  one  of  the  disadvantages  of  ether  as  compared  with 
chloroform. 

Ether  is  inflammable,  therefcn-e  a  thermocautery  cannot  be  employed 
about  the  mouth  and  face  when  it  is  used,  and  it  cannot  l)e  given  when 
an  unprotected  flame  is  near  by.  If  the  lamp  hangs  high  above  the  oper- 
ating, table  it  may  be  used,  as  its  fumes  sink.  It  is  not  decomposed  as 
chloroform  is  by  a  naked  flame. 

Preparation  of  Patient  for  Ether  Anaesthesia. — A  patient  should  re- 
ceive the  same  preparation  for  ether  ana'sthesia  as  has  been  described  for 
8 


100 


GENERAL   AND   LOCAL  ANESTHESIA 


chloroform.  Ether  anaesthesia  passes  through  the  same  stages  as  chloro- 
form; the  behavior  of  the  reflexes,  especially  the  pupillary  reflex,  and 
the  after  effects  are  very  similar.  The  pulse  remains  full,  and  is  even 
increased  in  volume  and  rapidity,  therefore  the  color  of  the  face  remains 
normal,  and  vessels  cut  during  an  operation  bleed  profusely.  An  in- 
creased amount  of  saliva  is  formed,  which  interferes  with  operations 
about  the  mouth  and  adjacent  to  it  and  embarrasses  respiration,  giving 
a  gurgling  character  to  the  breathing  and  causing  cyanosis.  Death  on 
the  table  from  sufl^ocation  is,  however,  less  likely  to  occur  than  subse- 
quent pneumonia  due  to  the  aspiration  of  saliva  and  its  irritating  action 
upon  the  respiratory  mucous  membrane. 

An  anaesthetist  who  has  a  tendency  to  catarrh  and  is  incited  to 
severe  spells  of  coughing  by  the  inhalation  of  small  amounts  of  ether, 
is  also  exposed  to  the  dangers  of  pneumonia.     The  administration  of 

ether  demands  the  same  careful  attention  that 
should  be  given  to  that  of  chloroform. 

Methods  of  Administering  Ether:  Open  and 

Closed. —  [Ether  may  be  administered  by  either 

the  open  or  closed  method.     The  former  is  very 

extensively   employed   in   America   at   present, 

and  Magaw,  who  had  such  a  large  experience 

with  ether,  prefers  it  to  any  other.     In  the  open 

method   the  ether  is  dropped  from  a  four  or 

eight  ounce  ether  can,  fitted  with  an  ordinary 

cork  with  a  groove  on  either  side. 

One  groove  should  be  filled  with  cotton  or  absorbent  gauze,  which 

should  extend  out  of  the  can  about  one  inch.    The  size  of  the  drop  can 

be  regulated  by  cutting  the  gauze 

or    cotton    in    a   certain   way   and 


Fig.  57. — Cloth  and  Pa 
PER  Cone. 


Vi  3 


Fig.  58. — Allis's  Inhaler. 


regulating  the  cork.     Magaw  usually  fixes  two  cans,  one  with  a  large 
dropper,  and  uses  it  until  the  patient  is  fully  under  the  anaesthetic,  and 


ETHER  ANAESTHESIA 


101 


then  changes  to  the  other  can  with  the  small  dropper,  and  continues  its 
use  during  the  operation. 

An  improved  Esmareh  inhaler,  covered  with  several  layers  of  gauze 
or  two  thicknesses  of  stockinet,  is  employed.  Of  couree  the  gauze  or 
stockinet  should  be  changed  after 
each  anaesthesia,  and  the  frame 
should  be  boiled.  The  ether  should 
be  dropped  as  slowly  and  as  care- 
fully as  if  it  W'ere  chloroform  until 
the  patient's  face  is 
flushed. 


Fig.  59. — Ether  Mask  After  Julliard- 

DUMONT. 


Then  a  few 
layers  of  gauze  are 
added,  and  the  ether  is  given  in 
larger  drops  and  more  rapidly  un- 
til the  patient  is  surgically  anaes- 
thetized, at  which  time  the  gauze 
may  be  removed.] 

In   the  closed  method   a  card- 
board mask  covered  with  muslin  or 

the  Julliard  mask,  improved  by  Dumont,   is  used.      If  the  cardboard 
mask  is  used,  several  layers  of  gauze  are  inserted  upon  which  tlie  ether 

is  dropped.  The  Julliard 
mask  consists  of  two  metal 
frames  placed  one  over 
the  other  and  connected 
by  a  hinge,  the  outer 
frame  being  covered  by 
oilcldtli.  Several  layers 
of  sterile  gauze  are  placed 
between  the  two  frames, 
and  a  flannel  jiad  npun 
which  the  ether  is  poured 
is  attached  to  the  iinier 
frame  (Fig.  oO).  In  be- 
giiuiing  tlie  anu'sthesia 
about  20  g.  of  ether  are 
poured  upon  the  flannel, 
and  the  mask  is  then 
gradually  placed  upon  the 
face.  After  one  or  two 
minutes  the  mask  is  removed,  the  same  amount  of  ether  is  ponivd  on  the 
flannel,  and  it  is  reapi)lied  again.  The  mask  is  then  surroinided  by  a 
towel  to  prevent  the  escape  of  ether  (Fig.  62). 


Fig.   60. — GnAouAL  Application   of  Mask  to   F.\ce. 
(From  Dumont.) 


102 


GENERAL   AND   LOCAL   ANAESTHESIA 


The  towel  is  removed  when  the  stage  of  surgical  anaesthesia  is  reached. 
The  mask  is  removed  from  time  to  time,  depending  upon  the  condition 
of  the  patient,  and  ether  is  poured  upon  it  if  necessary.  The  air  has 
free  access  to  this  mask,  there  is  no  accumulation  of  carbon  dioxide 
and  no  reduction  of  oxygen,  therefore  the  blood  is  well  aerated  (Du- 
mont). 

If^  saturated  mask  is  held  tightly  over  th'e  patient's  mouth  and  nose 
at  the  beginning,  he  experiences  a  sense  of  suffocation,  coughs,  becomes 
restless,  and,  after  a  few  inlialations,  suffocation  and  reflex  cardiac  or 
respiratory  paralysis  may  ensue.  For  this  reason  this  method,  which 
has  been  rightly  called  the  suffocating  method,  should  never  be  used. 

Administration  of  Morphin  and  Atropin  before  Ether  Anaesthesia. — 
The  mask  should  be  momentarily  withdrawn  during  the  stage  of  excite- 
ment w'hen  the  patient 
holds  his  breath  or  the 
inspirations  become  very 
deep.  It  is  much  more 
difficult  to  overcome  the 
stage  of  excitement  with 
ether  than  with  chloro- 
form. It  is  reconmiended 
for  this  reason  that  adults 
be  given  before  ether  an- 
ipsthesia  ^  gr.  morphin,  or, 
according  to  Dastre,  ^  gr. 
morphin  and  y^  gr.  of 
atropin,  as  the  latter  di- 
minishes secretion. 

During  the  anesthesia 
the  mask  should  be  re- 
moved fre(iuently,  in  order 
that  the  color  of  the  face 
may  be  noted,  the  pupil- 
lary reflexes  tested,  and 
the  saliva  wii)ed  away.  If  the  i>upil  reacts  rapidly,  more  ether  should 
be  poured  upon  the  mask,  which  should  then  be  replaced. 

Inhalers  by  Which  Amount  of  Ether  may  be  Regulated. — A  number 
of  difl'ereiit  inhalers  have  been  introduced  by  which  the  amount  of  ether 
administered  can  be  coMtrolled.  The  Clover,  Ormsby,  Squibb,  and  Ben- 
nett iiihnlcfs  arc  all  good,  and  are  eminently  satisfactory  when  used  by 
one  accustomed  to  them.  If,  however,  one  has  an  intimate  knowledge 
of  anu'sthcsia,  he  can  give  ethei-  just  as  satisfactorily  by  the  open  or 
closed  method  as  he  can  with  the  inhalers  above  mentioned.    They  have 


filter 

}/ 

i     ■ 

Fig.  61. — Lifting  the  Mask  to  Inspkct  Face  and 
Permit  of  Free  Access  of  Air.     (From  Dumont.) 


ETHER   ANESTHESIA 


103 


not  been  grenerally  adopted,  althouyli  expert  anaesthetists  who  have  be- 
come aceiistoined  to  either  one  of  the  inhalers  above  niciition.-d  spcjik-  of 
them  very  highly. 

Von  Arnd  has 
devised  an  appa- 
ratus with  a  com- 
pressible bag  for 
operations  about 
the  face  and 
mouth,  A  curved 
metal  end  piece  at- 
tached to  a  piece 
of  rubber  tubing 
which  is  connected 
with  the  bag  is  in- 
troduced into  the 
mouth.  A  mixture 
of  air  and  ether 
is  blown  into  the 
mouth  by  com- 
pressing the  bag. 
As  the  ether  is  still 
further  diluted  by 
the  inspired  air  there  is  but 
branes. 

Increased  Secretion  of  Saliva  and  Mucus  during  Ether  Anaesthesia. — 
.During  ether  ana\sthesia  the  respiratory  passages  must  be  kept  i'wo,  as 
in  this  way  the  dangers  of  suffocation  and  aspiration  pncuiiiDiiia  may  be 

avoitled.  CJurgling  ivspiration 
and  cyanosis  indicate  danger, 
whieli  is  increased  if  tlu'  saliva 
flows  into  the  larynx.  The 
flowing  of  saliva  into  tlie  phar- 
ynx and  larjaix  may  be  pre- 
vented if  the  head  is  held  on 
the  side.  The  mouth  should  be 
kept  open,  and  if  there  is  aii 
excessive  amount  of  mueus  and 
saliva  the  mouth  should  be 
cleaned  out  Avith  gauze. 

The  pharynx,  if  necessary 
the  larynx,  may  be  wiped  out  with  sponges  on  forceps.  The  latter  should 
not  be  employed  unless  absolutely'  necessary,  as  the  mechanical  irritation 


Fig.  62.- 


-SURROUNDING    THK    MaSK    AVITII    A    TuWEL. 

(From  Dumont.) 

little    irritation    of    the    mucous    mem- 


FiG.  63. — Bennett's  Ether  Inhaler. 


104  GENERAL   AND   LOCAL  ANESTHESIA 

produced  by  them  often  leads  to  the  secretion  of  more  mucus.  If  the 
jaw  drops  backward  and  interferes  with  respiration,  it  should  be  pushed 
and  held  forward.  The  tongue  should  be  drawn  forward  if  it  drops 
l)ackward  and  closes  the  larynx. 

Incomplete  Ether  Anaesthesia  for  Short  Operations. — Incomplete  ether 
anfesthesia.  may  be  used  for  short  operations.  Kronecher  recommends 
that  in  these  cases  the  anaesthesia  be  stopped  immediately  after  the  stage 
of  excitement,  while  Sudeck  places  the  mask  directly  upon  the  face  and 
performs  minor  operations  after  the  first  few  inspirations  in  the  so- 
called  "  ether  drunk."  The  after  effects  of  ether  are  about  the  same  as 
those  of  chloroform,  and  should  be  treated  in  the  same  way. 

Lung  Complications  following  Ether  Anaesthesia. — Broncho-pneu- 
monia, bronchitis,  and  oedema  of  the  lungs  are  more  common  after  ether 
than  after  chloroform  anaesthesia.  The  lung  complications  are  due  to 
the  aspiration  of  mucus  and  saliva,  the  use  of  impure  ether,  and  too  great 
concentration  of  the  ether  vapor.  Other  factors,  which  are  also  present 
in  chloroform  and  local  ana?sthesias,  such  as  cooling  of  the  surface  of  the 
body,  the  inability  to  cough  and  expectorate  after  abdominal  operations, 
are  also  contributing  factors. 

The  symptoms  of  lung  complications  usually  develop  on  the  second 
or  third  day.  Frequently  they  run  a  mild  clinical  course,  yet  they  may 
end  fatally,  especially  if  the  lungs  were  previously  diseased  (bronchitis, 
emphysema,  tuberculosis)  or  if  they  develop  in  old  and  feeble  patients. 

Ether  and  chloroform  have  about  the  same  effect  upon  a  preexisting 
nephritis,  the  albuminuria  following  ether  anfBsthesia  when  the  kidneys 
were  previously  sound  is  more  rapidly  recovered  from. 

Central  Anaesthetic  Palsies. — Central  anaesthetic  paralyses  are  more 
to  be  feared  when  ether  is  used,  as  it  raises  blood  pressure.  They  occur 
only  in  patients  who  at  the  time  the  ether  was  administered  had  a  high 
blood  pressure;  most  connnonly  in  patients  suffering  with  arterioscle- 
rosis, interstitial  nephritis,  and  lead  intoxication. 

Venous  Thrombosis. — Thrombosis  of  the  large  veins  of  the  pelvis  and 
lower  extremities  is  another  complication  which  may  follow  the  use  of 
ether.  It  is  often  associated  with  inflammatory  changes  in  the  pelvis, 
other  local  and  general  causes,  such  as  toxa'mia,  anu'mia,  cardiac  weak- 
ness, etc. 

Ether  increases  the  coagulability  of  the  blood,  and  at  times  when 
injected,  even  in  small  amounts,  into  the  veins  of  animals,  produces  ex- 
tensive thi'ombosis  (Tlanau,  K'iblx'rt).  According  to  the  experimental 
researches  of  Lexer  and  IMul/.cr,  thrombi  are  found  in  the  small  blood 
vessels  and  capillaries,  especially  of  the  lungs  and  kidneys,  after  the  in- 
halation of  either  chloroform  or  ether.  The  thrombosis  becomes  more 
extensivi!  th»;  longer  tlic  wniesthetic  is  administered. 


NITROUS  OXID   ANESTHESIA 


105 


CHAPTER   III 


NITROUS   OXID   ANESTHESIA 


[Nitrous  oxid,  K.O,  is  usually  obtained  by  heating  aniiiioniuiii  ni- 
trate, which  decomposes  at  an  elevated  temperature  and  forms  water  and 
nitrous  monoxid  (NH^NOg  =  2H2O -}- N„0).  The  product  is  washed 
by  passing  through  water,  which  soon  becomes  saturated  with  the  gas. 
The  gas  is  kept  in  retorts  or  tanks  obtained  from  manufacturers,  in 
which  it  is  reduced  to  a  liquid  form  by  strong  pressure.  The  bag  from 
which  the  gas  is  administered  is  filled,  and  the  amount  of  gas  regulated 
by  a  stopcock. 

Anaesthesia  is  rapidly  induced  by  nitrous  oxid,  and  the  gas  nuist 
be  given  continuously  or  intermittently,  the  mask  being  removed  for 
short  intervals,  when  the  patient  becomes  blue,  in  order  to  maintain 
surgical  anaesthesia. 

Nitrous  oxid  gas,  the  safest  of  the  ana'sthetics,  has  been  left  until 
recently  to  the  dentist  and  for  minor  operations,  although  years  ago  the 
feasibility  of  employing  it  for  prolonged  anaesthesia  was  thoroughly 
demonstrated  by  Bert,  Andrews,  and  others. 

In  the  last  eight  or  ten  years  nitrous  oxid  has  been  extensively  used 
by  the  general  surgeon  in  the  sequence  of  nitrous  oxid  and  ether.  In 
this  I  believe  it  has  no  very  great  value,  except  that  it  otters  an  agree- 
able ana\sthesia  to  the  patient. 

During  the  last  three  or  four  years  I  have  been  employing  nitrous 
oxid  and  air  as  a  general 
anaesthetic  in  an  increasing 
number  of  patients,  and  I 
have  been  so  much  impressed 
with  its  value  and  possibili- 
ties of  wide  application  that 
I  feel  warranted  in  urging 
its  more  general  use. 

Roughly  speaking,  chloro- 
form anaesthesia  has  a  mor- 
tality of  1  in  2,000;  ether, 
1  in  5,000 ;  and  nitrous  oxid 
gas,  1  in  50.000  to  1  in  100,000.  Gas  is  the  most  agreeable  anaesthetic  to 
take,  and  is  the  most  rapid  anaesthetic,  taking  usually  about  sixty  seconds. 
It  is  seldom  followed  by  nausea  or  vomiting,  pneumonia  or  bi-onchitis  or 
nephritis  or  secondary  changes  in  the  tissues.  If  properly  administered 
Avith  air,  an  anesthesia  of  a  half  hour  or  an  hour  can  be  secured. 


Fig.  64. — Bennett's  Nitrous 
Oxid  Inhaler. 


106  GENERAL   AND    LOCAL   ANESTHESIA 

I  began  using  it  in  cases  where  ether  and  chloroform  were  specially 
contraindicated,  as  in  operations  on  the  kidneys,  such  as  nephrotomy  for 
anuria,  abscess,  etc.  I  then  extended  it  to  kidney  stone  operations  and 
nephrectomies.  And  finding  how  easy  it  was  to  maintain  satisfactory  an- 
testhesia  for  long  periods,  I  have  gradually  increased  the  range  of  its  use 
until  now  I  am  employing  gas  in  a  large  proportion  of  my  general  cases. 

It  is  the  anaesthetic  of  choice  in  reducing  fractures  and  dislocations, 
in  opening  abscesses  and  felons,  in  breaking  up  adhesions  in  joints,  in 
draining  empyemas  and  lung  abscess,  in  exploratory  laparotomies,  in  gall 
bladder  work,  removing  stones  and  drainage  in  kidney  work,  nephrotomy, 
nephrectomy,  and  nephrolithotomy,  in  bladder  work,  suprapubic  cystot- 
omy for  stone  and  in  suprapubic  prostatectomy,  in  draining  appendiceal 
abscesses  and  cases  of  general  peritonitis,  in  colostomy,  in  gastrostomy, 
in  enterostomy,  in  repair  of  t.yphoid  perforation,  in  repair  of  perfo- 
rating gastric  and  duodenal  ulcers,  in  hernia  operations,  especially  for 
relief  of  strangulated  hernia,  in  varicocele,  in  open  operation  for  hydro- 
cele, in  castration,  in  amputations,  excepting  the  largest  joints,  in  re- 
moving tumors,  as  fatty  tumors. 

There  are  some  operations  in  which  it  cannot  be  very  well  employed, 
especially  in  those  about  the  perineum  (ha-morrhoid  operations,  for  in- 
stance), there  being  a  great  tendency  for  the  patient  to  straighten  the 
limbs  out  and  intei'fere  with  the  procedure. 

Operations  where  very  complete  relaxation  of  the  muscles  is  desirable 
are  not  well  suited  for  gas  anesthesia. 

Gas  anaesthesia  has  certain  disadvantages.  It  is  expensive ;  this,  how- 
ever, could  be  overcome  in  a  large  hospital  by  manufacturing  the  gas 
in  an  apparatus  in  the  operating  room,  as  is  done  in  their  offices  by 
some  dentists  who  make  a  specialty  of  extracting  teeth  and  employ  large 
amounts  of  the  agent. 

The  apparatus  is  a  bit  cumbersome  to  carry  around  in  private  oper- 
ating, and  still  this  is  not  a  matter  of  much  moment,  as  two  or  three 
cylinders  and  a  gas  bag  and  mouthpiece  can  easily  be  carried  in  a  small 
dress  suit  case. 

To  one  unaccustomed  to  the  dark  color  of  the  patient's  face  and  the 
dark  blood  in  the  wound,  this  method  seems  more  dangerous  than  ether 
or  chloroform  anaesthesia. 

1'he  ana'sthesia  is  not  as  profound  as  that  of  ether  or  chloroform,  and 
the  occasional  talking  of  the  patient  may  be  disconcerting  to  one  not 
familiar  with  the  method. 

In  spite  of  these  disadvantages,  the  great  safety  of  the  anaesthesia,  the 
great  rai)idity  of  its  action,  tlie  great  comfort  with  which  the  patient 
can  take  it,  llic  gtcat  fi-eedoiii  Tfom  nausea,  the  almost  immediate  recov- 
ery from  tlic  iiii:i'stlicsi;i,  the  gi-cat   freedoiii   froiii  lung  complication,  the 


ACCIDENTS   DURING    ANAESTHESIA,    AND    IIOW   TO   MEET   THEM      1()7 

great  freedom  from  kidney  complication,  the  great  freedom  from  exten- 
sive fatty  degenerations  of  liver,  kidney,  and  heart,  which  may  follow 
chloroform  anaesthesia  and  to  a  less  degree  ether  ana'sthesia — all  of  these 
combined  make  ana'sthesia  by  nitrous  oxid  gas  and  air  the  method  of 
choice  in  a  considerable  proportion  of  general  surgical  cases.] 


CHAPTER    IV 

ACCIDENTS    DURING    AN-^STHESIA,    AND    IloW    To    MEl-.T    TJIKM 

Every  phj^sician  should  have  an  intimate  knowledge  of  the  accidents 
which  may  occur  during  anaesthesia,  and  should  be  thoroughly  conver- 
sant with  the  methods  which  should  be  employed  to  combat  them.  All 
these  accidents  are  grouped]  under  the  term  asphyxia,  although  this 
term,  from  the  Greek.  o-^S^ttv,  meaning  to  pulsate,  refers  only  to  the 
absence  of  the  pulse.  The  discipline  of  the  assistants  must  be  perfect 
in  order  to  prevent  confusion  and  loss  of  time,  and  surgeons  in  charge 
should  keep  cool  and  collected.  If  an  accident  happens,  the  first  thing 
that  should  be  done  is  to  remove  the  mask. 

The  accidents  that  may  arise  are  suffocation  and  rcspiratoru  and 
cardiac  paralysis. 

Suffocation. — Suffocation  is  the  result  of  mechanical  interference  Avith 
the  air  passages  leading  to  partial  or  complete  occlusion.  It  may  be 
produced  hy  mucus  and  saliva,  which  are  secreted  in  large  quantities 
when  ether  is  given ;  by  vomitus,  which  is  expelled  when  the  patient  is 
awakening,  or  during  anjesthesia  when  the  anaesthetic  is  not  given  evenly, 
and  in  intestinal  obstruction  when  enormous  quantities  are  discharged. 
[An  anaesthetist  should  always  remember  this  danger,  which  occurs 
so  often  in  patients  suffering  with  ileus.  Large  quantities  of  vomitus 
are  raised,  and  unless  the  anaesthetist  is  careful  and  the  patient  is 
watched  until  fully  awake,  the  vomitus  may  collect  in  the  pharynx 
and  flow  into  the  larynx,  literally  drowning  the  patient.]  If  tlieiv  is 
any  interference  with  the  air  passages  the  head  should  be  immediately 
lowered  and  turned  to  the  side,  and  a  mouth  gag  inserted,  in  order  to 
permit  the  nnicus  and  saliva  or  vomitus  to  flow  out.  If  the  operation 
is  not  yet  completed,  the  anaesthesia  should  be  continued  in  this  posi- 
tion, and,  as  a  rule,  the  vomiting  quickly  subsides.  IMaterials  which 
collect  in  the  recesses  of  the  cheeks  should  be  removed  with  steel  sponges. 
If  gurgling  respirati(m  and  cyanosis  indicate  that  mucus  and  saliva 
or  vomitus  has  entered  the  larynx,  a  steel  sponge  should  be  passed  into 
this  organ  and  the  material  removed  by  a  twisting  motion.     In  desperate 


108  GENERAL   AND   LOCAL   ANJiiSTIIESIA 

cases  a  tracheotomy  may  have  to  be  performed,  and  the  aspirated  mate- 
rial sucked  out  by  a  catheter,  or  something  introduced  to  incite  coughing. 

A  number  of  different  methods  may  be  employed  to  prevent  blood 
flowing  into  the  larynx  during  operations  upon  the  jaws,  cheeks,  lips, 
nose,  and  floor  of  the  mouth.  This  is  a  grave  danger,  as  the  aspiration 
of  blood  is  frequently  followed  by  broncho-pneumonia.  This  may  be 
prevented  by  position,  the  head  being  allowed  to  hang  over  the  end  of 
the  operating  table,  as  advocated  by  Rose,  or  by  performing  a  preliminary 
tracheotomy  and  inserting  a  tampon  canula  through  which  the  anes- 
thetic may  be  given.  The  pharynx  and  aperture  of  the  larynx  may  then 
be  tamponed.  [It  should  be  remembered,  however,  that  tracheotomy 
is  rather  a  serious  procedure,  accompanied  by  fairly  high  mortality.  This 
should  not  be  employed  when  simpler  methods  will  suffice.] 

In  operations  upon  the  mouth  the  blood  may  be  constantly  wiped 
away  with  sponges  on  forceps,  or  the  recesses  of  the  cheek  may  be  tam- 
poned, while  in  operations  upon  the  nose  the  posterior  nares  may  be  tam- 
poned. In  some  cases  it  is  well  to  induce  only  a  partial  anfesthesia ;  the 
reflexes  are  then  preserved  and  the  patient  can  expectorate  the  blood. 

Foreign  bodies,  such  as  tobacco,  artificial  teeth,  and  candies,  may  pass 
into  the  air  passages  during  anaesthesia  and  cause  suft'ocation.  Of  course 
all  foreign  bodies  should  be  removed  before  anipsthesia  is  begun,  but  if 
such  an  accident  should  happen,  the  mouth  gag  should  be  inserted  and 
the  foreign  body  removed  with  the  finger  or  curved  forceps. 

The  tongue  may  be  spasmodically  pressed  against  the  pharynx  during 
the  stage  of  excitement,  embarrassing  respiration ;  usually  this  is  asso- 
ciated with  spasm  of  the  diaphragm  and  the  other  muscles  of  respiration. 
The  jaws  should  then  be  innnediately  opened  and  the  tongue  drawn  for- 
ward with  tongue  forceps.  If  this  does  not  suffice  the  hyoid  bone  should 
be  elevated,  using  von  Bergmann's  method  (vide  p.  110)  and  artificial 
respiration  begun. 

During  deep  anaesthesia  respiration  may  be  embarrassed  by  the  suck- 
ing in  of  the  lips,  cheeks,  and  ah\'  nasi.  The  lips  are  drawn  in,  especially 
in  people  witliout  teeth  and  patients  who  have  had  a  harelip  repaired. 
It  may  also  be  embarrassed  by  a  kinking  of  the  trachea,  when  the  head 
is  in  a  poor  position. 

If  the  nasal  passages  are  occluded  by  polypi,  hypertrophied  tur- 
binate bones,  tonsils,  or  a  tampon,  the  jaws  nmst  be  kept  separated  by 
a  mouth  gag  and  the  tongue  held  forward. 

'^I'he  surgeon  should  be  able  to  prevent  deaths  from  suffocation  occur- 
ring during  anaesthesia. 

Eespiratory  Paralysis. — Respiration  may  cease  in  the  first  stage  of 
ana'sllicsia,  the  (liai)hragm  being  in  the  position  of  expiration,  perhaps 
associated  with  a  spasm  of  the  glottis.     This  condition  is  apparently  of 


ACCIDENTS   DURING   ANESTHESIA,   AND   HOW  TO   MEET  THEM     109 

reflex  origin,  following  stimulation  of  the  trigeminal  branches  sui)plying 
the  nasal  mucous  membrane,  and  occiu-s  most  frecjuently  when  large 
quantities  of  ether  are  administered  quickly.  Tiie  pulse  renuiins  good  and 
the  pupillary  reflex  is  retained.  If  artificial  respiration  is  perfoiim-d 
quickly,  the  patient  may  vomit  aud  then  begin  to  l)reathe  again. 

If  the  anaesthetic  is  then  forced  because  the  patient  vomits,  this  con- 
dition may  oeeur  again.  These  cases  are  known  as  "  bad  anaesthesias." 
If  the  condition  occurs  whenever  the  patient  is  ana-sthetized,  thei'e  is  usu- 
ally syphilis,  tuberculosis,  or  some  other  disease  of  the  nose,  pharynx,  or 
larynx.  Painting  of  the  nuicous  membranes  with  a  five  per  cent  solution 
of  cocain  before  the  anasthesia  is  begun  may  be  of  value  in  these  cases. 

If  the  cessation  of  respiration  occurring  in  the  first  stage  of  anaes- 
thesia is  overlooked  and  more  anesthetic  administered,  death  may  occur 
from  cardiac  paralysis,  which  is  also  probably  of  a  reflex  nature,  follow- 
ing stimulation  of  the  superior  laryngeal  nerve. 

Cessation  of  respiration,  occurring  in  deep  anaesthesia,  the  result  of 
administering  too  nnich  ana'sthetic,  is  nuicli  more  dangerous  than  that 
above  described.  The  pupils  become  dilated  and  do  not  react,  and  the 
heart  stops  beating  after  some  seconds  or  minutes.  If  artificial  respira- 
tion and  heart  massage  are  begun  immediately,  the  pulse  returns  and 
then  the  respirations,  but  the  patient  remains  for  a  long  time  in  deep 
anaesthesia  with  contracted,  fixed  pupils. 

Cardiac  Paralysis. — The  worst  and  most  serious  accident  is  that  of 
sudden  cessation  of  the  heai't  beat,  which  may  occur  as  the  so-called 
early  syncope,  even  in  the  first  and  second  stages  of  ana?sthesia.  It  is 
most  frequent  when  chloroform  is  given,  and  is  probably  caused  by 
paralysis  of  the  cardiac  centers  or  acute  dilatation  of  the  heart  develop- 
ing during  the  stage  of  excitement.  It  occurs  most  commonly  in  pa- 
tients with  some  lesion  of  the  myocardium,  such  as  fatty  degeneration 
so  common  in  chronic  alcoholics  and  following  severe  infectious  disease; 
in  patients  with  a  chlorotie  and  lymphatic  constitution;  in  anaemias  fol- 
lowing injury  or  internal  haemorrhages,  leukaemia  ;  in  shock,  and  severe 
psychical  excitement. 

It  may  be  caused  during  deep  anaesthesia  by  a  reflex  paralysis  fol- 
lowing irritation  of  the  sensory  nerves  (e.  g.,  by  traction  upon  the  sper- 
matic cord,  by  rough  manipulation  of  the  abdominal  viscera,  being  analo- 
gous to  shock  induced  by  Goltz  tapping  experiments)  and  by  the  a<l min- 
istration of  too  much  anaesthetic,  especially  Avhen  there  is  an  anaenua 
of  the  brain,  the  result  of  severe  haemorrhages  or  cardiac  weakness.' 


>The  athetoid  flexor  movements  of  the  fingers,  which  are  regarded  by  Koblanck  as 
a  positive  sign  of  approaching  cardiac  failure,  are  frequently  present  during  perfectly 
normal  anaesthesia,  and  the  author  does  not  attach  much  significance  to  them. 


no 


GENERAL  AND   LOCAL  ANESTHESIA 


AVheii  these  accidents  occur  tlie  pulse  becomes  wenlc  and  irregular,  the 
face  pallid  and  corpsolike,  the  pupils  dilated  and  fixed.  Irregular  respira- 
tory movements  continue  for  some  minutes  after  the  heart  stops  beating. 
Fortunately  such  accidents  are  but  rarely  seen  when  ether  is  used, 
being  more  frequent  when  chloroform  is  employed.     If  such  an  accident 

occurs  the  patient  should  be 
inverted  immediately  or,  bet- 
ter, the  foot  of  the  table 
should  be  elevated  to  at  least 
45°,  the  object  of  the  eleva- 
tion being  to  overcome  the 
cerebral  anasmia  and  to  favor 
the  return  of  the  venous  blood 
which  has  accumulated  in  the 
splanchnic  area  to  the  right 
side  of  the  heart.  Artificial 
respiration,  massage  of  the 
heart,  transfusion  of  salt  so- 
lution should  also  be  em- 
ployed. Action  nuist  be  im- 
mediate. If  after  fifteen 
minutes  there  is  no  response 
to  the  treatment,  the  patient 
rarely  recovers. 

The   physician   is   not   re- 
sponsible    for     deaths     from 
cardiac   paralysis   if   the    an- 
a\sthetic    has    been    properly 
given,    if   there   were   proper 
indications    for    general    an- 
aesthesia   {vide   p.    117),    and 
if     effective     measures     were 
promptly  instituted  to  relieve 
the  conditions. 
The  purpose  of  artificial  respiration  is  to  carry  oxygen  to  the  blood, 
to  favor  the  flow  of  oxygenated  blood  to  the  respiratory  and  cardiac 
centers,  and  to  hasten  the  excretion  of  the  anaesthetic  from  the  lungs. 

Freeing  of  Air  Passages. — Naturally  the  air  passages  nuist  be  free 
before  artilicial  respiration  is  begun.  The  mouth  should  be  opened  with 
a  mouth  gag,  of  which  Ihere  are  a  number  of  different  varieties.  The 
Ileister  or  the  K()nig-l^)ser  should  ])e  insei-ted  behind  the  back  teeth  on 
one  side,  after  the  jaw  has  been  pushed  forward;  the  von  Bruns  mouth 
gag  if  used  should  be  applied  between  the  ineisoi-  teeth.    The  index  finger 


Fig.  65. — Showing  Inversion  of  Patient  and 
Mktiiod  of  Pkrfokming  Artificial  Respii{A- 
TiON  SiMUi.TANEousLY.  (Hare.)  From  Park's 
Modern  Surgery. 


ACCIDENTS   DURING   ANESTHESIA,    AND    HOW   TO    MI:KT   THEM      111 


may  then  be  passed  over  the  dorsum  of  the  tongue  and  the  epiglottis, 
until  the  easily  palpable  hyoid  bone  is  reached,  which  should  be  drawn 
forward  and  upward.  The  tongue  may  be  drawn  forward  more  effect- 
ively by  this  procedure,  introduced  by  von  Bergmann,  than  by  the  use 
of  tongue  forceps. 

Artificial    Eespiration. — Artificial    respiration    is    usually    performed 
according  to  the  method  introduced  by  Silvester. 

The  patient  is  placed  in  a  horizontal  or  slightly  inverted  position; 
the  operator  stands  behind  him,  grasps  the  arms  flexed  at  the  elbows, 
presses  them  against  the  sides  of  the  chest,  and  then  draws  them  back- 
ward until  they  are  stretched  horizontally  above  the  head.  By  this  pro- 
cedure the  ribs  are  raised  by  traction  of  the  pectoral  muscles  and  arti- 
ficial inspiration  is  produced. 
When  the  arms  are  depressed 
expiration  is  produced.  [Ar- 
tificial respiration  should 
never  be  performed  more 
rapidly  than  the  normal  re- 
spiratory movements,  eighteen 
to  twenty  complete  movements 
being  performed  in  a  minute. 
If  performed  more  rapidly  and 
roughly,  artificial  respiration 
is  apt  to  do  about  as  much 
harm  as  good.]  Care  should 
be  exercised  not  to  fracture 
ribs,  especially  in  old  people 
with  rigid  thoracic  walls. 

Cardiac  Massage.  —  Heart 
massage,  according  to  Konig 
and  Maas,  may  be  performed 
by  the  physician  holding  the 
tongue  forward.  He  should 
stand  upon  the  right  side  of 
the  patient,  using  the  left 
hand  to  hold  the  tongue,  and 
should  place  the  right  hand 
fiat  upon  the  pra^cordial  re- 
gion,  alternately  raising  and 

depressing  the  wrist  joint  and  ball  of  the  thumb,  the  number  of  com- 
plete movements  corresponding  to  the  numbei-  of  heart  beats. 

Artificial  respiration  and  heart  massage  should  be  continued   until 
lungs  and  heart  resume  spontaneous  activity,  or  if  there  is  no  reaction 


Fig.  66. 


-Same  .\s  Fig.  65.      From  Park's  Modern 
Surgery. 


112  GENERAL  AND   LOCAL   ANESTHESIA 

for  at  least  one  hour.  Intravenous  infusion  of  physiological  salt  solu- 
tion should  always  be  employed  with  these  methods. 

Rhythmic  Traction  of  the  Tongue,  Adrenalin,  Faradism,  Direct  Mas- 
sage of  Heart,  etc. — Besides  these  important  measures  above  noted  others 
may  be  mentioned,  such  as  stimulation  of  the  respiratory  nuisculature  by 
rhythmic  traction  of  the  tongue  (Laborde),  faradic  stimulation  of  the 
phrenic  nerves,  injection  of  a  few  c.c.  of  a  one  per  cent  solution  of 
adrenalin  (Gottlieb,  Mankowsky),  the  injection  of  a  few  c.c.  of  cam- 
phorated oil,  and  direct  massage  of  the  heart.  The  latter  recommended 
by  Prus  for  desperate  cases,  was  first  employed  by  Tui^er.  It  has  not 
been  successful,  although  in  a  number  of  cases  the  heart  has  been  stimu- 
lated to  beat  for  a  short  time  (Zesas,  Sick). 

Death  occurring  during  angesthesia  is  generally  ascribed  to  the  effects 
of  the  anaesthetic.  If  it  occurs,  a  statement  should  be  prepared  concern- 
ing the  indications  for  the  operation  and  general  anaesthesia;  the  results 
of  previous  examinations,  which  should  have  excluded  all  conditions  con- 
traindicating  the  use  of  ether  or  chloroform,  or  only  permit  of  their  use 
in  case  of  emergency ;  the  operative  technic,  the  accidents,  and  the  meth- 
ods employed  to  counteract  them.  This  statement  should  be  signed  by 
all  present  and  by  the  ana-sthetist  or  operator  who  is  directly  responsible. 

It  is  practically  impossible  to  make  a  short  synopsis  of  lines  of  treat- 
ment that  should  be  instituted  to  meet  the  different  accidents  which  may 
occur  during  anaesthesia,  but  the  following  suggestions  may  be  made: 

1.  If  the  respiratory  movements  are  spasmodic  in  character,  with 
entrance  of  some  air,  there  is  marked  cyanosis,  the  blood  becomes  dark, 
and  respirations  are  embarrassed,  but  the  pulse  is  still  present,  it  is 
generally  sufficient  to  open  the  mouth,  draw  the  tongue  forward,  and 
clear  the  air  passages.    Prompt  action,  as  a  rule,  removes  the  conditions. 

2.  If  the  respiratory  movements  have  ceased,  perhaps  the  result  of 
reflex  paralysis  occurring  at  the  beginning  of  anaesthesia,  or  antemia  of 
the  brain,  but  the  pulse  is  present  and  the  pupils  react,  artificial  respira- 
tion should  be  performed  after  the  respiratory  passages  have  been  freed. 
Recovery  with  vomiting  is,  as  a  rule,  rapid. 

3.  If  the  respiratory  movements  have  ceased,  the  pulse  is  present  but 
weak,  the  pupils  dilated  but  do  not  react,  anaesthesia  having  been  carried 
beyond  the  normal  point,  the  foot  of  the  table  should  be  elevated,  arti- 
ficial respiration  and  heart  massage  begun.  In  favorable  cases  the  pupils 
contract,  the  pulse  becomes  better,  spontaneous  respirations  return  in 
at  least  ten  minutes,  and  the  patient  remains  for  some  time  in  the  stage 
of  deep  ana'sthcsia  with  coutiacted,  fixed  pupils.  In  the  worst  cases  the 
pulse  does  not  retiii-ii  and  death  is  the  result. 

4.  If  the  ])iilsc  is  lost,  the  respii-ations  sii])orficial  or  suspended,  there 
is  maxinnuu   dilatation  of  the  pupils  and  corpselike  pallor,  the  foot 


DIFFERENT   METHODS   OF   INDUCING   ANAESTHESIA  113 

of  the  table  should  be  elevated,  artificial  respiration  and  heart  massage 
performed,  and  transfusion  of  salt  solution  given.  Patients  in  this  con- 
dition rarely  recover,  even  when  correct  treatment  is  instituted  imme- 
diately. 


CHAPTER   V 

DIFFERENT    METHODS   OF   INDUCING    AN.-1':STIIESIA.      CHOICE   OF   METHODS 

Anaesthesia  by  Sequence. — It  is  at  times  desirable  and  advantageous 
to  ehanue  anaesthetics  during  anjesthesia.  Anaesthesia  may  be  started 
with  chloroform  or  with  some  other  anaesthetic,  such  as  laughing  gas  or 
ethyl  bromid,  and  continued  with  ether  (Kocher)  ;  this  method  is  to  be 
especially  recommended  if  during  long  operations  the  heart's  action  be- 
comes weak  or  cardiac  weakness  is  feared  in  anaemic  and  weak  patients. 

Some  surgeons  (Madelung,  Kolliker)  begin  with  ether  and  continue 
with  chloroform,  as  the  dangers  of  the  latter,  whicli  are  especially  pro- 
nounced during  the  initial  stage  of  anaesthesia,  may  be  avoided  in  this 
way.  The  long  stage  of  excitement  accompanying  ether  anaesthesia  is 
often  dangerous  to  patients  with  heart  lesions,  and  in  these  cases  a  few 
drops  of  chloroform  administered  in  the  beginning  quiets  the  heart  and 
induces  anaesthesia,  which  should  ])e  continued  with  ether,  rapidly. 

Administration  of  Morphin  before  General  AnaeLthesia. — In  .some 
cases  a  small  dose  of  morphin  may  be  given  to  advantage  before  chloro- 
form or  ether  anae.sthesia  is  begun.  One  sixth  to  one  (piarter  of  a  grain 
should  then  be  injected  subcutaneously  from  fifteen  to  thirty  minutes 
before  the  anaesthesia  is  begun.  It  quiets  the  patient,  and  tliei-e  is  less 
reaction  when  the  general  anaesthesia  is  begun  and  less  is  re(iuired  to 
maintain  anaesthesia.  Morphin  combined  with  atropin  is  esiiecially  to 
be  recommended  when  alcoholics  are  to  be  ana'stheti/ed.  It  is  fre(|U(>ntly 
administered  before  ether  is  given  as  the  atrojuii  lessens  the  aniount 
of  secretion. 

The  patient  under  the  action  of  morphin  falls  into  a  semistupor.  and 
but  little  anaesthetic  is  recjuired;  even  if  conscious,  patients  expei-i- 
ence  but  little  pain.  Often  they  react  when  spokt'u  to  loudly,  and  many 
operators  attempt  to  maintain  this  condition  during  operations  about 
the  mouth,  as  the  cough  refiex  is  preserved  and  the  bh)od  may  be  pre- 
vented in  this  way  from  flowing  back  iuto  the  larynx.  It  is  proliably 
better,  however,  in  this  case  not  to  give  morphin,  as  it  is  then  difficult 
to  keep  the  patient  in  this  condition,  as  he  passes  rapidly  into  the  deeper 
stages  of  anaesthesia  in  which  the  reflexes  are  abolished.  It  is  better  to 
use  chloroform  and  produce  only  a  superficial  anaesthesia. 


114  GENERAL   AND   LOCAL   ANESTHESIA 

Anaesthetic  Mixtures. — Mixtures  of  different  ana?sthetics  have  been 
reconnneudetl  and  used.  The  Billroth  mixture  is  composed  of  three 
parts  of  chloroform,  one  of  ether,  and  one  of  alcohol ;  the  so-called 
Vienna  mixture  contains  one  part  of  chloroform  and  three  of  ether ;  the 
Linhart  mixture,  one  part  of  alcohol  and  four  of  chloroform.  Schleich's 
g:eneral  anaesthetic  contains  ether,  chloroform,  and  petroleum-ether,  and 
has  a  boiling  point  which  corresponds  to  body  temperature. 

Braun  has  devised  an  apparatus  for  mixing  ether  and  chloroform, 
by  which  the  amount  of  each  may  be  accurately  measured,  and  mixtures 
of  different  composition  made,  b}^  which  each  ana:^sthetic  may  be  giver 
separately  or  in  sequence. 

Scopolamin-Morphin  Anaesthesia.  —  Scopolamin-morphin  anaesthesia 
has  many  disadvantages  and  dangers.  It  has  been  employed  quite 
extensively  of  late,  but  the  results  have  not  been  such  as  to  warrant 
recommendation.  In  the  cases  reported  up  to  the  present  time  the  death 
rate  has  been  higher  than  that  following  the  use  of  chloroform  and 
ether. 

Both  ether  and  chloroform  have  their  advantages  and  disadvantages, 
their  adherents  and  opponents.  In  America  ether  is  used  much  more 
extensively  than  chloroform,  and  unless  there  is  some  positive  contra- 
indication it  should  be  employed. 

There  is  a  possibility  of  death  occurring  whenever  a  general  anaes- 
thetic is  administered,  but  when  it  does  occur  it  is  often  difficult  to 
determine  whether  the  anaesthetic  was  the  direct  cause  of  death  or  not. 
It  may  have  been  due  to  the  inexperience  or  gross  ignorance  of  the 
anaesthetist,  but  it  should  be  remembered  that  fatal  results  have  occurred 
even  during  minor  operations  when  a  general  anasthetic  was  not  admin- 
istered. Some  of  these  deaths  are  probably  due  to  fright,  others  to  pul- 
monary embolism.  The  first  time  Simpson  was  about  to  use  chloroform, 
the  fiask  l)roke  and  the  chloroform  was  spilled.  The  operation  was  begun 
without  any  ana'sthetic,  and  the  patient  suddenly  died.  It  is  probable 
that  if  chloroform  had  been  administered  in  this  case,  it  would  never 
have  been  tried  again  as  a  general  ana'sthetie. 

[Late  Poisonous  Effects  of  Anaesthetics.— A  number  of  articles  have 
appeared  lately  dealing  with  the  late  i)oisonous  effects  of  anaesthetics. 
General  ana'sthetics,  especially  chloroform,  produce  changes  in  important 
viscera,  resulting  in  metabolic  changes  which  often  prove  fatal.  The 
symptoms  produced  ))y  tliesc^  changes  were  grouped  under  different  terms 
before  tlicir  etiological  and  clinical  significances  were  clearly  recognized. 
Tlic  possibility  of  the  late  poisonous  effects  of  anasthesia  developing 
should  alwa.ys  be  consido-cd  in  dctcniiining  the  anasthetic  which  should 
be  used  in  each  case. 

Bevan  and   Kavill.  al'ler  llie  ohseivalion  of  a  fatal  case  and  a  com- 


DIFFERENT   METHODS   OF   INDUCING   ANESTHESIA  115 

parative  study  of  a  number  of  cases  reported  in  the  literature,  come  to 
the  following  conclusions: 

1.  Ani^sthetics,  especially  chloroform  (ether  to  a  very  limited  de- 
gree), can  produce  a  destructive  effect  on  the  cells  of  the  liver  and  kid- 
neys and  on  the  muscle  cells  of  the  heart  and  other  muscles,  resulting  in 
fatty  degeneration  and  necrosis,  very  similar  to  the  effects  produced  in 
phosphorus  poisoning. 

2.  The  constant  and  most  important  injury  done  is  that  to  the  liver. 

3.  This  injury  to  the  liver  cells  is  in  direct  proportion  to  the  amount 
of  the  anaesthetic  employed  and  the  length  of  the  ana^^sthesia. 

4.  Certain  individuals  exhibit  an  idiosyncrasy  or  a  susceptibility  to 
this  form  of  poisoning  which  it  is  difiieult  to  explain. 

5.  There  are  certain  predisposing  causes  which  favor  this  destructive 
effect  of  chloroform,  among  -svliich  are:  (a)  age — the  younger  the  pa- 
tient the  more  susceptible;  (h)  causes  which  lower  the  general  vitality 
of  the  individual  and  probably  the  vitality  of  the  liver  cells,  such  as 
diabetes,  previous  recent  anaesthesias,  infections  by  pus  germs,  diph- 
theria, intoxications  from  a  dead  foetus  in  the  uterus,  a  gangrenous  mass 
in  the  abdominal  cavity,  etc.;  (c)  exhaustion  due  to  ha?moi'rhage;  (d)  ex- 
haustion due  to  starvation;  (e)  exhaustion  due  to  wasting  diseases,  such 
as  carcinoma;  (/)  lesions  which  have  resulted  in  extensive  fatty  degener- 
ations, such  as  occur  in  the  limbs  in  infantile  paralysis;  (g)  chronic  dis- 
eases involving  both  liver  and  kidney,  such  as  cirrhosis  and  nephritis. 

6.  As  a  result  of  this  fatty  degeneration  and  necrosis  of  the  liver 
cells,  toxins  are  produced  either  by  the  liver  cells  themselves  or  as  a 
result  of  the  failure  of  these  cells  to  eliminate  substances  which  under 
normal  conditions  they  do,  but  which  under  these  abnormal  conditions 
they  fail  to  do,  and  these  substances,  therefore,  may  accumulate  and 
produce  toxic  effects. 

7.  These  toxins  produce  a  definite  symptom-complex  which  makes 
its  appearance  from  ten  to  one  hundred  and  fifty  hours  after  the  anaes- 
thesia. This  symptom-complex  consists  of  vomiting,  restlessness,  delir- 
ium, convulsions,  coma,  Chej'ne-Stokes  respiration,  cyanosis,  icterus  in 
varying  degree,  and  usually  terminates  in  death. 

8.  It  is  probable  that  milder  degrees  of  this  poisoning  are  recovered 
from,  and  that  the  transient  icterus  noticed  after  chloroform  ana-sthesia 
without  other  evident  cause  is  due  to  such  poisoning,  and  many  cases 
which  exhibit  restlessness,  fright,  mild  delirium,  di-owsiness,  etc.,  after 
anaesthesia  may  be  due  to  the  same  cause. 

9.  This  disease  is  an  hepatic  toxaemia ;  the  toxins  producing  it,  hepatic 
toxins ;  and  possibly  the  previous  condition  making  its  development 
easily  possible  should  be  described  as  liver  insutlficiency.  Just  as  we 
have  for  a  long  time  recognized  a  condition,  uraemia,  in  w^iich  we  find 


116  GENERAL   AND   LOCAL   ANAESTHESIA 

arising  from  a  variety  of  noxious  agents — ana'sthetics,  poison,  infections, 
pregnancy,  etc.,  affecting  the  secreting  cells  of  the  kidney  and  preventing 
their  normal  function — a  pathologic  condition,  accompanied  with  a  cer- 
tain definite  symptom-complex;  so  we  must  now,  we  believe,  recognize  a 
condition  involving  the  liver  which  may  be  caused  by  a  variety  of  noxi- 
ous agents  (antesthetics,  poisons,  infections,  pregnancy,  etc.),  affecting 
the  secreting  cells  of  the  liver  and  preventing  their  normal  function,  a 
pathologic  condition  which  we  must  describe  as  he])atic  toxaemia,  accom- 
panied with  a  certain  symptom-complex,  and  showing  certain  definite 
changes  post  mortem. 

We  believe  that  the  condition  of  acute  fatty  degeneration  of  the  liver 
with  resulting  hepatic  toxaemia  is  as  definite  a  pathologic  entity  as  is 
acute  pancreatitis  with  fat  necrosis. 

10.  As  by-products  in  this  toxaemia,  but  not  as  the  essential  poisons, 
are  found  acetone,  diacetic  acid,  and  beta-oxybutyric  acid  in  the  blood 
and  urine. 

11.  Post-mortem  examination  reveals  fatty  degeneration  of  the  liver, 
fatty  degeneration  and  mild  degree  of  inflammation  of  the  kidneys,  and, 
in  extreme  cases,  fatty  degeneration  of  heart  and  other  muscles.  The 
lesion  of  the  liver  we  believe  to  be  the  overshadowing  and  important  one, 
and  the  one  which  is  responsible  for  the  s.ymptoms  and  fatal  result.  The 
injury  to  the  liver,  in  some  cases,  is  so  great  as  to  result  in  practically  a 
total  destruction  of  the  organ. 

12.  Somewhat  similar  hepatic  toxa?mias  resulting  from  fatty  degen- 
eration of  the  liver  cells  occur  in  other  conditions,  and  are  accompanied 
by  very  similar  symptoms.  These  occur  in  iodoform  and  phosphorus 
poisoning,  diabetes,  puerperal  eclampsia,  and  acute  yellow  atrophy  of 
the  liver. 

13.  This  fatty  degeneration  of  the  liver  with  hepatic  toxtpmia  follow- 
ing anaesthesia  is  almost  invariably  due  to  chloroform  in  the  fatal  cases. 
Ether  is  seldom  the  cause  of  a  death  of  this  kind. 

14.  This  serious  and  even  fatal  late  effect  of  chloroform,  which  has 
heretofore  not  been  generally  recognized,  nnist  still  further  limit  the  use 
of  this  powerful  and  dangerous  agent. 

15.  The  possibility  of  the  development  of  hepatic  toxaemia  makes 
chloroform  distinctly  contraindicated  in  those  cases  in  which  there  exist 
the  conditions  which  seem  to  favor  its  development — i.  e.,  diabetes,  sepsis, 
starvation,  haemorrhage,  the  presence  of  intoxication  from  dead  material, 
the  presence  of  fatty  degenerations,  as  already  cited,  after  infantile 
paralysis,  and  lesions  of  the  liver.  The  susceptibility  of  children  to  this 
hepatic  toxaemia  7iiust  be  recognized.  That  chloroform  is  cApable  of  pro- 
ducing these  serious  late  poisonous  effects  is  a  strong  argument  against 
its  employment,  and  an  argument  in  favor  of  the  more  general  use  of 


DIFFERENT   METHODS   OF   INDUCING   ANESTHESIA 


ir 


ether;  and  yet  we  are  confronted  at  times  with  the  Charybdis  of  ether 
pneumonia  on  the  one  hand,  and  the  Scylla  of  chloroform  hepatic  tox- 
aemia on  the  other. 

16.  The  recognition  of  this  danger  of  hepatic  toxa-mia  is  a  .strong 
argument  against  the  empk)yment  of  eliloroform  for  h)iig  anjvsthcsia,  as 
it  can  be  shown  that  a  two-hour  chloroform  ana'sthesia  is  almost  invari- 
ably fatal  to  rabbits  and  guinea  pigs,  from  fatty  degeneration  and  necro- 
sis of  the  liver  cells;  and  a  two-hour  chloroform  anu'sthcsia  in  man  is  an 
exceedingly  dangerous  thing.  | 

Mortality  Following  the  Different  Anaesthetics. — It  is  difficult  to  de- 
termine by  statistical  studies  the  value  and  safety  of  an  ana'sthetic.  as  the 
effects  of  operations,  injury,  and  disease  must  also  be  taken  into  con- 
sideration. According  to  Gurlt's  statistics  (1890-97)  one  death  oc- 
curred in  2,075  cases  of  chloroform  and  one  death  in  5.112  cases  of  ether 
anaesthesia.  AVilliams's  statistics,  covering  a  period  of  ten  years,  show 
that  one  death  occurred  in  1,236  cases  of  chloroform,  and  one  death  in 
4,860  cases  of  ether  anaesthesia.  The  statistics  collected  by  Julliard  are 
as  follows : 


Administrations 

Deaths 

Rate 

Chloroform 

524,507 
314,738 

161 
21 

1  in    3,258 

Ether 

1  in  14,987 

Statistics  appear  to  favor  ether.  Konig,  however,  has  not  seen  a 
fatal  result  in  7,000  cases  of  chloroform  anaesthesia,  and  in  von  Berg- 
mann's  clinic  and  polyclinic  during  an  interval  of  twelve  years,  in  wliich 
time  about  8,000  chloroform  anaesthesias  were  administered,  the  author 
saw^  but  one  fatal  result. 

Indications  and  Contraindications  for  Ether  and  Chloroform. — Each 
anaesthetic  has  its  contraindications,  one  being  less  dangerous  under  cer- 
tain conditions  than  the  other. 

Chloroform  is  to  be  avoided  and  ether  used  instead  whenever  there 
is  a  disturbance  of  cardiac  function  or  demonstrable  disease  of  heart 
muscle.  It  should  never  be  forgotten,  hoAvever,  that  ether,  and  particu- 
larly the  lung  complications  which  may  follow  its  use,  may  be  a  source 
of  danger  if  the  heart  is  affected.  Chloroform  may  be  used  in  valvular 
disease  w'ithout  danger  if  compensation  is  good. 

Chloroform  is  to  be  preferred  to  ether  when  the  lungs  are  diseased 
or  respiration  interfered  with,  as  the  result  of  narrowing  of  the  respira- 
tory passages  (tracheal  stenosis,  goiter,  intlanmiatory  (I'deinn  of  the 
mucous  membranes,  etc.) .  These  conditions  also  favor  aspiration  of  saliva 
or  vomitus.    General  anaesthesia  is  contraindicated  :  (1)  In  all  conditions 


118  GENERAL  AND   LOCAL  ANESTHESIA 

in  which  both  ether  and  chloroform  are  contraindieated ;  (2)  if  the  pa- 
tient is  greatly  excited  before  the  operation;  (3)  in  constitutional  dis- 
eases, in  which  the  bodily  resistance  is  greatly  reduced  (diabetes,  severe 
anaemias,  leukaemia,  obesity,  status  lymphaticus  or  thymicus,  exophthal- 
mic goiter)  ;  (4)  in  general  weakness  (syncope,  shock,  hoBmorrhage, 
cachexia)  ;  and  (5)  advanced  nephritis.  Finally,  ana?sthetics  should  not 
be  given,  unless  unavoidable,  to  women  in  the  second  half  of  pregnancy, 
as  an  abortion  may  result. 

In  all  conditions  in  which  general  anoesthesia  is  associated  with  great 
danger,  local  anaesthesia  should  be  used  if  possible.  Death  has  resulted, 
however,  from  the  use  of  local  anix'sthetics  in  excitable,  weakened  sub- 
jects. Von  Eiselberg  saw  a  fatal  result  following  innnediately  a  strumec- 
tomy  which  was  done  with  Schleich's  infiltration  anaesthesia  for  the  re- 
lief of  Basedow's  disease.  Von  Bergmann  lost  a  diabetic  patient  while 
amputating  a  thigh  under  local  aniesthesia,  and  the  author  has  seen  many 
patients  collapse  when  the  same  method  has  been  employed. 

The  physician  must  decide  whether  a  local  or  general  anaesthetic  is 
indicated,  and  must  choose  the  anesthetic  to  be  used  in  each  individual 
case.  If  he  has  studied  the  case  carefully,  and  has  noted  the  indications 
and  contraindications,  he  cannot  be  held  responsible  for  any  accidents 
which  may  occur. 

Literature. — Blauel.  LTeber  den  Blutdruck  wiihrend  der  Aether-  und  Chloroform- 
narkose.  Beitr.  z.  klin.  Chir.,  Bd.  31,  1901,  p.  271. — Borntrdgcr.  Strafrechtl.  Verant- 
wortlichkeit  d.  Arztes  bei  Anwendung  des  Chloroforms.  Berlin,  1891. — Braun.  L'eber 
Mischnarkose  u.  deren  Ration.  Verwend.  Chir.-Kongr.  Verhandl.,  1901,  II,  p.  136. — 
P.  Bruns.  Ein  automat.  Mundsperrer.  Beitr.  z.  klin.  Chir.,  Bd.  19,  1897,  p.  253. — 
Czempin.  Die  Technik  der  Chloroformnarkose.  Berlin,  1897. — Dumont.  Handb.  der 
allgem.  und  lokalen  Anasthesie.  Urban  u.  Schwarzenberg,  1903. — Flatau.  Ueber 
Narkosenlahmungen.  Zentr.  f.  Grenzgeb.,  1901,  p.  385. — Gartner.  Ueber  eixien  neuen 
Apparat  zur  oi^tischen  Pulskontrolle  in  der  Narkose.  Zentralbl.  f.  Chir.,  1903,  No.  36. 
— Hofmann.  Aethertroj)f narkose.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  65,  1903,  p. 
403. — Kappelcr.  Chlorofornmarkose.  Kochers  Enzyklopiidie,  1901; — Chloroformie- 
rung  mit  messbaren  Chloroformluftmischungen.  Chir.-Kongr.  Verhandl.,  1890,  II,  p. 
79. — Kionka.  Narkose,  in  Eulenburgs  Realenzyklopadie,  1898. — Kohlanck.  Die 
Chloroform-  u.  Aethernarkose  in  der  Praxis.  Wiesbaden,  1902. — Kocher.  Chirurg. 
Operationslehre.  Jena,  1902. — Kochmann.  Zur  Frage  der  Morphium-Skopolamin- 
Narkose.  Miinch.  med.  Woch.,  1905,  No.  17. — Konig.  Herzmassage.  Chir.-Kongr. 
Verhandl.,  1893,  I,  p.  21. — Kraske.  Ueber  kiinstl.  Atmung  und  kiinstliche  Herzbe- 
wegung.  ("hir.-Kongr.  Verhandl.,  1887,  II,  p.  279. — Ldseck,  Rijs,  Zahradnicky.  Skopola- 
min-Morphium-Narkose.  Zentralbl.  f.  Chir.,  1905,  p.  611,  612. — Lewin.  Note  zur 
I'emploi  du  vinaigre  contre  les  vomissements  consocut  ifs  a  la  rhloroformisation.  Revue 
de  chirurgie,  T.  15,  1895,  p.  786. — v.  Mikulicz.  ITeber  die  Narkose.  Deutsche  Klinik, 
]'.d.  8,  \9(n.—Benno  Midler.  Narkologie.  Leii>zig,  1903.— il/u/srr.  Sonuner  1906 
noch  nicht  erschiencn. — Netlel.  Ueber  cincn  Fall  von  Thymustod  bei  Lokalanjisthesie. 
Archiv  f.  klin.  Chir.,  lid.  73,  1904,  p.  637. — v.  Niederhdusern.  Die  Skojiolamin-Mor- 
phium-Narkosc.  I. -I).  Bern,  1905. — Offergehl.  Experim.  Beitrag  zur  toxischen 
Wirkung  des  Chloroforms  auf  die  Nieren.     Archiv  f.  klin.  Chir.,  Bd.  75,  1905,  p.  758. — 


LOCAL   AN.ESTIIESL\  110 

Schnciderlin.  Die  Skopolamin-CIIyosciiO-Morphiiuu-Xarkose.  Miinch.  mccl.  Woch., 
l'J03,  p.  371. — P.  Sick.  Zur  operutiveii  Ilerziiiassage.  Zentralbl.  fiir  Chir.,  1903,  p. 
USl. — Zesas.  Ueber  die  Massage  des  freigelegten  Herzeus  im  ChloroformkoUaps. 
Zentralbl.  f.  Chir.,  1903,  p.  588. 


CHAPTER   VI 

LOCAL   ANJi:STHESL\ 

Attempts  to  diminish  locally  the  pain  sense,  so  that  painless  opera- 
tions might  be  performed,  were  made  even  in  olden  times.  Constriction 
of  the  extremities  or  compression  of  large  nerve  trunks  used  in  earlier 
times  is  no  longer  employed,  because  of  the  dangers  of  temporary  or 
permanent  paralysis. 

Anaesthesia  Induced  by  Freezing — Ether  Spray  and  Ethyl  Chlorid. 
— At  the  present  time  physical  and  chemical  methods  of  different  kinds 
are  employed.  Anaesthesia  by  freezing  is  a  physical  method  which  has 
come  into  more  general  use  since  the  ether  spray  was  introduced  by 
Richardson  in  1866.  It  reduces  the  temperature  of  the  cutaneous  area 
upon  which  it  phiys  to  five  degrees  above  zero  (F.),  and  the  skin, 
which  must  be  perfectly  dry  before  the  spray  is  applied,  suddenly 
becomes  white  after  a  few  minutes,  the  nerves  lose  their  excitability  and 
conductivity,  and  sensation  is  lost.  Anaesthesia  induced  by  the  ether 
spray  is  superficial  and  lasts 
but  a  short  time.  When  the 
area  thaws  out  a  burning 
sensation  is  experienced. 

Chlorid    of    ethyl,    which   (^/^  Ftg.  67.— Chlortd  of  Ennx. 

may  be  bought  in  glass  or 
metal  flasks  provided  with  detachable  tops,  is  siini)l('r  in  its  application 
than  the  ether  spray.  It  boils  at  52°  F.,  and  when  tlie  flask  is  hehl  in 
the  hand  a  fine  stream  is  discharged,  Avhich  evaporates  rapidly.  'I'he  flask 
should  be  held  from  30  to  40  cm.  from  the  ai-ea  to  be  operated  upon,  and 
as  the  temperature  is  rapidly  reduced  it  is  frozen  and  rendei-cnl  aiuvs- 
thetic  more  quickly  than  when  the  ether  spi-ay  is  employed. 

Anaesthesia  by  freezing  is  suited  only  for  small  superficial  incisions 
or  for  the  introduction  of  an  aspirating  needle,  and  is  to  be  especially 
recommended  for  incisions  into  circumscribed  cutaneous  and  subcutane- 
ous inflammatory  processes. 

Cocain  Hydrochlorate. — Cocain  hydrochlorate  is  the  most  important 
chemical  agent  for  producing  local  ana'sthesia.  It  was  introduced  into 
ophthalmology  by  Roller  in  1884,  and  has  become  indispensable  as  a 


120  GENERAL   AND   LOCAL   ANESTHESIA 

local  anaesthetic.  It  may  be  used  in  different  ways  in  producing  anaes- 
thesia. Mucous  membranes  may  be  painted  or  sprayed  with  a  solution 
of  it;  the  drug  may  be  injected  around  or  directly  into  nerves,  into  the 
tissues,  or  subdural  space  of  the  cord. 

Anaesthesia  by  Spraying  or  Painting  with  Cocain  Solutions. — The 
mucous  membranes  of  the  mouth,  nose,  pharynx,  and  larynx  may  be 
rendered  anaesthetic  rapidly  by  spraying  or  painting  them  with  a  five 
or  ten  per  cent  solution  of  cocain.  If  inflamed  the  swelling  rapidly 
diminishes  as  the  vessels  contract.  Hollow  organs  such  as  the  bladder 
may  be  rendered  antesthetic  by  irrigating  them  with  a  one  per  cent  solu- 
tion. The  conjunctiva  may  be  rendered  anesthetic  by  dropping  a  few 
drops  of  a  one  per  cent  solution  upon  the  cornea.  Only  the  surfaces  of 
mucous  membranes  are  anesthetized  in  this  way,  but  a  number  of  opera- 
tions not  involving  deeper  tissues,  such  as  the  removal  of  nasal  polyps 
and  small  superficial  tumors  and  the  opening  of  abscesses,  may  be  per- 
formed. 

Infiltration  Anaesthesia. — Infiltration  anesthesia  is  employed  very  ex- 
tensively in  minor  surgery.  Schleich  has  done  more  by  experimental 
work  than  anyone  else  to  popularize  and  extend  the  usefulness  of  this 
form  of  local  anaesthesia.  Infiltration  anesthesia  consists  in  the  injec- 
tion of  "weak  solutions  into  the  tissues.  AVeak  solutions  of  cocain  are 
much  preferred  to  the  stronger  solutions,  as  the  former  are  more  reliable, 
and  larger  quantities  may  be  used  without  the  fear  of  toxic  symptoms. 

Schleich  has  three  solutions  of  the  following  compositions : 

Solution  No.  1 — Strong 

Cocain  hydrochlorate gr.  3 

Morphin  hydrochlorate   gr.  | 

Chlorid  of  sodium   gr.  3 

Distilled  sterilized  water 5  3|- 

Solution  No.  2 — Normal 

Cocain   hydrochlorate    gr.  1^ 

Morphin  hydrochlorate   g^-  f 

Chlorid  of  sodium   gr.  3 

Distilled  sterilized  water 5     3| 

Solution  No.  3 — ^Yeak 

Cocain  liydrochlorate gr.  ^ 

IMorphin  hydrochlorate   gr.  § 

Chlorid  of  sodium   .~ gr.  3 

Distilled  sterilized  water 3     3| 


LOCAL   ANESTHESIA 


121 


Schleich's  tablets  may  be  bought  already  prepared,  and  whoii  the 
solution  is  required,  the  number  of  tablets  required  to  make  a  solution 
of  a  certain  strength  should  be  added  to  a  definite  amount  of  water. 
Distilled  sterilized  water  should  be  used  for  making  the  solution,  as  the 
coeain  is  decomposed  and  becomes  ineffective  when  it  is  boiled. 

Technic  of  Injecting  Coeain  Solution. — When  the  coeain  solution  is 

injected  into  the  skin  a  definite  technic  must  be  employed.    An  ordinary 

hypodermic   or   larger   syringe  may  be   used   for 

malcing  the  injection.    The  needle  may  be  inserted 

at  a  point  previously  made  ana'stlictie  l)y  freezing, 


Fig.  69. — Lxfiltratiox  of  Deep  L.wer  of  Skin. 

and  should  then  be  passed  almost  parallel  to  the 

surface  of  the  skin.   The  point  of  the  needle  should 

be  kept  in  the  cutis,  and  should  not  be  passed  into 

the  subcutaneous  tissues.     If  there  is  resistance  to 

the  piston  when  the  injec- 
tion is  made,  the  needle  is 

in  the  correct  position. 
The     needle     is     then 

gradually  inserted  into  the 

wheal     previously     raised 

until    the    entire    line    of 

incision    is    cocainized. 

AVherever    the    solution 

passes,  a  white  hard  wheal 

is  raised.     AVhen  the  cutis 

is    sufficiently    infiltrated, 

some    of    the    solution 

should    be    injected    into 

the    subcutaneous    tissues. 

If   it  is  the    intention   of  Ji 

the  operator  to  carry  the 
incision  deeper  the  solution  should  be  injected  into  fascia'  and  muscle,  and 
if  the  bone  is  to  be  exposed  it  should  be  injected  into  the  periosteum. 


Fig.  68. — Syringe  Hold- 
ing 10  OR  15  c.c.  Which 
May  Be  Used  for  In- 
jecting THE  COCAIN 
SOI^UTION. 


Fig.   70. — Infil- 
tration An.es- 

THESI.V. 


122 


GENERAL  AND   LOCAL  ANESTHESIA 


If  a  large  amount  of  cocain  is  used  the  injected  area  is  transformed  into 
a  hard  tumor-like  infiltration  which  is  anaesthetic. 

The  solution  should  be  freshly  prepared  before  bein<jj  used.  The 
needle  should  fit  tightly  and  the  barrel  should  be  provided  with  a  good 
handle,  so  that  firm,  even  pressure  may  be  exerted.  A  number  of  differ- 
ent apparatus  have  been  devised  for  injection  of  the  solution  in  which 
the  air  pressure  in  the  flask  containing  the  solution  is  raised  by  forcing 
in  air  Avith  an  ordinary  syringe  or  bicycle  pump.  The  solution  is  then 
slowly  forced  out  of  a  rubber  tube,  to  which  a  needle  is  attached,  and 
the  tissues  are  evenly  infiltrated.  [In  the  Bevan  clinic  a  one  tenth  of 
one  per  cent  solution  of  cocain  is  used  for  anaesthesia  of  the  skin,  and 
a  one  per  cent  solution  for  nerve  blocking.  The  ordinary  hypodermic 
syringe  has  been  found  very  satisfactory  for  injecting  the  solution.] 


Fig.   71. — Matas  Apparatus,   Introducing  the  Air. 

The  strongest  Schleieh  solution  has  the  following  advantages:  The 
injections  are  less  painful,  and  as  less  of  the  solution  is  required  a  better 
view  of  the  tissues  may  be  had  and  their  anatomical  relations  may  be 
more  easily  recognized.  It  has  the  disadvantage  that  enough  of  the 
solution  cannot  be  employed  with  safety  to  render  anaesthetic  large  areas. 
"When  the  weakest  solution  is  employed  the  injection  may  be  painful, 
and  so  much  of  the  solution  is  required  that  the  appearance  of  the  tis- 
sues may  be  so  changed  and  the  anatomical  relations  so  altered  that  it 
may  be  practically  impossil:)le  to  find  small  subcutaneous  tumors,  glands, 
or  foreign  bodies. 

Infiltration  angesthesia  may  be  employed  when  there  is  no  acute  in- 
flammation. The  injury  of  the  tissues  by  the  needle,  and  the  danger  of 
forcing  bacteria  and  their  toxins  into  healthy  surrounding  tissues,  pre- 
vent its  use  in  infections.  Besides,  in  acute  inflammation  it  may  be 
necessary  to  make  the  incision  layer  by  layer,  and  this  is  practically 
impossible  when  infiltration  anfpsthesia  is  used. 

Many  major  operations  (removal  of  large  tiimors,  thyroidectomy,  her- 
niotomy, resection  of  ribs)  may  be  performed  under  infiltration  anaes- 
thesia. Fre(|uently,  however,  the  patients  become  greatly  excited,  and 
general  ana'stliesia  is  to  be  preferred  when  there  are  no  contraindications. 


LOCAL   ANESTHESIA  123 

Anaesthesia  "by  Nerve  Blocking. — Anaesthesia  by  nerve  blockino:,  in 
which  the  injections  are  made  into  the  tissues  surrounding  the  nerves, 
or  directly  into  the  latter,  has  recently  been  improved  by  Braun  and  may 
be  employed  in  a  number  of  different  ways. 

According  to  Corning  and  Oberst,  this  method  is  especially  suitable 
for  producing  anaesthesia  of  the  fingers  and  toes.  It  should  be  em- 
ployed as  follows:  The  finger  or  toe  to  be  anaesthetized  is  first  rendered 
bloodless  by  applying  a  constrictor  about  its  base.  Then  four  subcu- 
taneous injections  of  a  one  half  or  one  per  cent  eocain  .solution  are 
made  about  the  base  of  the  digit  distalward  to  tlie  constrictor  until  a 
circular  swelling  is  raised  by  the  solution.  All  the  nerve  connections 
are  then  blocked,  the  digit  becomes  anaesthetic  in  five  minutes,  and 
remains  so  until  the  constrictor  is  removed. 

This  procedure  can  only  be  employed  for  the  incision  of  acute  in- 
fiannnatory  processes,  when  the  injection  can  be  made  into  healthy  tissues. 

According  to  Hackenbruch,  anaesthesia  may  be  induced  by  the 
subcutaneous  injections  of  a  one  per  cent  solution  of  eocain  about 
the  field  of  operation  when  only  superficial  operations  are  to  be  at- 
tempted. 

Larger  parts  of  the  extremities,  such  as  the  hand  and  foot,  forearm, 
and  leg,  may  be  rendered  completely  anaesthetic,  according  to  Braun  and 
others,  if  after  the  application  of  an  elastic  constrictor  a  one  per  cent 
solution  of  eocain  is  injected  distalward  to  the  constrictor  about  the 
larger  nerve  trunks  (perineural  injection).  Subcutaneous  injections  of 
Schleich's  solution  may  be  combined  with  this  method,  the  injections 
being  made  parallel  to  the  extremity,  completely  or  only  partially  a])out 
it,  blocking  effectually  the  cutaneous  nerves. 

The  Use  of  Adrenalin  in  Cocain  Solutions. — Bi-aun  discovered  that 
the  action  of  cocain  and  cocain  solutions  could  be  proh)nged  and  in- 
creased about  fourfold  if,  just  before  being  nsed,  a  few  drops  of  a 
1:  1,000  solution  of  adrenalin  were  added  to  them.  It  also  renders  un- 
necessary the  troublesome  and  often  painful  elastic  constriction  without 
which  anaesthesia  cannot  be  successfully  produced  with  one  half  to  one 
per  cent  solutions.  The  vessels  are  constricted  and  an  iscluvmia  pro- 
duced by  this  agent,  and  therefore  absorption  is  delayed.  A  comphete 
anaesthesia  develops  in  thirty  minutes  after  perineural  injections. 

According  to  Braun,  not  more  than  five  drops  of  the  adrenalin  solu- 
tion .should  be  used,  and  it  should  be  added  to  the  cocain  solution  just 
before  the  latter  is  injected. 

For  the  perineural  injection  of  the  largcer  nerve  trunks  a  syringeful 
of  a  one  per  cent  solution  of  cocain  or  eucain,  to  which  are  added  from 
one  to  three  drops  of  adrenalin  solution  for  each  c.c. ;  for  the  injection 
of  subcutaneous  nerves  along  their  course  a  one  half  per  cent  solution 


124  GENERAL   AND   LOCAL   ANESTHESIA 

"\ 
with  the  addition  of  one  drop   of  adrenalin  solution  for  each  10  c.c. 

should  be  employed. 

According  to  Braun,  this  procedure  is  best  suited  for  producing  an 
anaesthesia  of  the  fingers,  toes,  hand,  and  foot,  of  the  nerve  trunks  in 
the  lower  third  of  the  forearm  and  leg,  the  ulnar  nerve  at  the  elbow, 
the  peroneal  and  tibial  nerves  in  the  popliteal  space,  the  long  saphenous 
nerve,  the  superior  clunial  and  supraclavicular  nerves.  The  following 
nerves  in  the  head  and  neck  may  be  blocked  by  this  method :  the  super- 
ficial cervical,  the  auricularis  magnus,  and  the  superior  laryngeal,  bi- 
lateral blocking  of  which  produces  a  very  satisfactory  prolonged  anaes- 
thesia of  the  entire  larynx,  the  supra-  and  infraorbital  nerves,  and  the 
long  cutaneous  nerves  of  the  scalp. 

Spinal  Anaesthesia. —  [Lumbar  or  spinal  anresthesia  was  first  employed 
by  Corning;  it  was  rediscovered  and  improved  by  Bier.]  This  form  of 
anaesthesia  is  produced  by  injecting  weak  solutions  of  cocain  or  closely 
allied  drugs  into  the  lumbar  meningeal  sac. 

The  following  technic  is  employed :  The  patient  is  either  placed  upon 
his  side  or  seated  upon  a  table  with  his  back  toward  the  operator,  the 
body  being  somewhat  flexed  in  order  to  separate  the  laminae  and  render 
the  intervertebral  spaces  wider.  A  thin  canula  10  c.c.  in  length  is  then 
inserted  between  the  spinous  processes  of  the  third  and  fourth  lumbar  ver- 
tebrge,  just  above  a  line  uniting  the  highest  points  of  the  crista  ilii  (as  in 
Quincke's  lumbar  puncture),  or  between  the  spines  of  the  second  and 
third  lumbar  vertebrae.  This  needle  is  then  passed  into  the  lumbar  sac, 
and  a  few  drops  of  cerebrospinal  fluid  are  allowed  to  flow  out,  and  then 
the  solution  is  slowly  injected.  The  solution  mixes  with  the  cerebro- 
spinal fluid  and  acts  upon  the  intradural  nerve  roots  and  trunks,  espe- 
cially upon  sensory  bundles  lying  in  the  posterior  part  of  the  cauda 
equina.  Loss  of  sensation,  often  accompanied  by  some  motor  paralysis, 
occurs  in  from  ten  to  fifteen  minutes  and  lasts  for  difl^erent  lengths  of 
time,  even  up  to  two  hours.  The  anaesthesia  is  most  marked  in  the 
extremities,  about  the  anus  and  the  perineum,  and  is  usually  so  complete 
that  any  operation  may  be  performed  below  the  level  of  the  navel. 

In  many  cases  the  anaesthesia  is  incomplete  or  does  not  develop ; 
sometimes,  when  the  canula  has  been  directed  lateralward  between  the 
nerves  of  the  cauda  ecjuina,  the  amcsthesia  occurs  only  upon  one  side 
(Donitz). 

Spinal  anaesthesia  as  first  employed  was  not  practical.  The  mortality 
was  high,  and  unplensjint  symptoms  (chills,  sweating,  nausea,  vomiting, 
collapse)  and  after  effects  (headache,  dizziness,  vomiting,  fever,  paresis 
of  the  muscles  of  the  extremities,  and  paralysis  of  the  muscles  of  the 
eye)  were  fre(iueiil,  especially  so  when  the  anaesthesia  extended  above  the 
level  of  the  navel. 


LOCAL  ANESTHESIA  125 

Bier  is  of  the  opinion  that  the  addition  of  adrenalin  solution  makes 
spinal  ana'sthesia  practical.  Adrenalin  prevents  the  dill'usion  of  tlie 
anaesthetic  toward  the  brain,  and  diminishes,  even  if  it  does  not  prevent, 
the  unpleasant  symptoms  and  after  effects.  Care,  however,  should  always 
be  exercised ;  too  large  amounts  of  fluid  and  too  strong'  solutions  should 
not  be  injected;  the  injection  should  })e  made  slowly;  and  elevation  of 
the  pelvis  should  be  avoided  (Braun).  Elevation  of  the  pelvis  is  of 
advantage  when  the  anaesthesia  does  not  extend  upward  high  enough 
(Donitz). 

Stovain,  with  the  addition  of  adrenalin  solution,  is,  according  to  Bier, 
usually  best  suited  for  spinal  anaesthesia,  although  unpleasant  symptoms 
and  collapse  may  develop  when  it  is  used.  The  solution  may  be 
bought  sterilized  and  ready  for  use.  It  comes  in  small  sealed  glass 
bulbs,  containing  2  c.c,  in  which  are  found  0.08  stovain,  0.0022  sodium 
chlorid,  and  0.00026  adrenalin.  Only  half  of  this  solution  is  used  for 
an  injection  (therefore  0.04  of  stovain). 

All  the  chemical  methods  of  producing  anaBsthesia  are  associated  with 
danger,  as  the  drugs  which  are  used,  especially  coeain,  are  toxic. 

Cocain  Poisoning. — Acute  coeain  poisoning  occurs  most  frequently 
when  concentrated  solutions  are  used,  or  when  the  solution  is  accidentally 
injected  into  a  vein.  The  first  danger  may  be  avoided  by  using  one  per 
cent  or  weaker  solutions;  the  latter  by  aspirating,  when  deep  injections 
are  made,  to  determine  before  the  injection  is  made  Miiether  or  not  a 
vein  has  been  entered.  Never  more  than  0.1  of  cocain  should  be  injected 
when  a  one  per  cent  solution  is  used,  and  never  more  than  0.15  when  a 
one  tenth  per  cent  solution  is  used.  In  patients  who  are  esi)eeially  sus- 
ceptible, toxic  symptoms  may  develop  after  spraying  or  painting  the 
mucous  membranes  with  a  five  per  cent  solution. 

The  symptoms  of  cocain  poisoning,  which  manifest  themselves  shortly 
after  the  injection  or  application  of  the  solution,  are  anxiety,  a  sense  of 
oppression,  dizziness,  collapse,  convulsions,  paralyses  of  different  groups 
of  muscles,  and  finally  respiratory  and  cardiac  paralysis  ending  in  death. 
There  is  no  chemical  antidote  to  cocain  poisoning.  The  patient  should 
be  placed  in  the  horizontal  position,  with  the  lower  extremities  elevated 
to  overcome  the  cerebral  anamiia ;  coffee,  cognac,  and  subcutaneous  in- 
jections of  camphor  should  be  given.  As  soon  as  the  respiratory  move- 
ments become  irregular,  artificial  respiration  should  be  begun  and  con- 
tinued until  improvement  is  noted  or  the  patient  is  past  all  hope  of 
recovery. 

A  number  of  different  substitutes  for  cocain  (tropacocain.  eucaiu, 
acoin,  holoeain,  aneson,  orthoform,  nirvanin,  ana^sthesin.  subcutin,  sto- 
vain, alypin,  novocain),  which  are  less  toxic  but  have  about  tlie  same 
action,  have  been  introduced.     Tropacoeain,  eueain,  and  novocain  have 


126  GENERAL  AND   LOCAL  ANESTHESIA 

about  the  same  action  as  coeain,  and  have  the  advantages  of  l)oing  less 
toxic  and  of  not  being-  decomposed  by  boiling  (Braun). 

The  cheaper  preparations,  eucain  and  novocain,  are  to  be  recom- 
mended for  ordinary  use  in  strengths  of  from  0.1  to  1  per  cent,  being 
prepared  with  physiological  salt  solution. 

There  are  a  number  of  important  points  to  be  considered  when  de- 
ciding Avhether  a  general  or  a  local  anaesthetic  should  be  administered. 

If  the  operation  can  easily  be  performed  under  local  anesthesia,  it 
should  be  recommended  to  the  patient.  Then,  if  he  desires  a  general 
anaesthetic,  the  surgeon  should  not  persist  in  giving  a  local  one,  as  the 
excitement  accompanying  this  form  of  anaesthesia  is  frequently  associ- 
ated with  grave  dangers  (fatal  collapse). 

It  is  better  to  employ  general  anaesthesia  in  the  performance  of  major 
operations,  even  when  local  ana'sthesia  is  technically  possible.  Under 
local  anaesthesia  the  time  required  for  the  performance  of  the  operation 
is  lengthened,  and  the  dangers  of  wound  infections  are  increased.  The 
fear  w^hich  many  patients  have  of  a  major  operation  and  the  attention 
which  they  pay  to  the  details  of  the  same  may  cause  dangerous  syncope. 
If  the  anaesthesia  is  not  complete,  the  patient  often  complains  bitterly, 
and  the  operative  skill  and  technic  of  the  surgeon  suffers. 

If  there  are  contraindications  to  general  anaesthesia,  local  anassthesia 
or  lumbar  anaesthesia  should  be  attempted  even  when  major  operations 
are  to  be  performed.  If  the  anesthesia  is  not  a  success  or  the  patient 
becomes  greatly  excited,  general  amesthesia  should  then  be  carefully 
induced. 

Spinal  anesthesia  is  to  be  attempted  in  operations  below  the  level 
of  the  navel,  when  general  anesthesia  is  contra  indicated,  and  the  opera- 
tion is  to  be  extensive  and  upon  a  part  Avhere  local  ana\sthesia  is  impos- 
sible. Spinal  anaesthesia  is  especially  suited  for  operations  upon  weak 
old  people,  and  for  amputations  for  diabetic  and  senile  gangrene. 

In  studying  the  after  effects  of  major  operations  performed  under 
local  ana'sthesia,  von  Mikulicz  has  made  the  important  observation  that 
pneumonia  following  laparotomies,  herniotomies,  and  thyroidectomies,  are 
about  as  frequent  after  local  as  after  chloroform  anesthesia. 

LiTEKATUKK. — Bier.  Uel>or  den  jetzigen  Stand  der  Ri'ickenmarksanusthesie,  ihre 
Berechtigung,  ihre  Vorteile  und  Nat-hteile  gcgeniiber  anderen  Atiasthesierungs- 
methodcn.  Chir.-Kongr.  Vorhandl.,  1905,  II,  p.  115. — Braun.  Die  Lokalaniisthesie,  ihre 
wissenschaftlifhon  rirnndlagon  und  praktische  Bodeutnng.  Leipzig,  1905; — I^^eber 
einige  none  (irtHche  Aniisthetiea.  (Stovain,  Alyjiin,  Novokain.)  Dentsche  med.  Wochen- 
schr.,  1905,  p.  1667. — Donitz.  Teehnik,  Wirkung  u.  spezielle  Inchkation  der  Riicken- 
marksanasthesie.  Chir.-Kongr.  Verhandl.,  1905,  II,  p.  527. — Dumont.  Ilandb. 
der  allgem.  und  lokalen  Anasthesie,  190:i — Rerlus.  La  cocaine  en  chirurgie.  Paris, 
1895. — Schleich.  Scluncirzlose  Operalionen.  BerHn,  1894 J — Ueber  lokale  Anasthesie. 
Die  deutschc  Klinik.  I'xk  S,  1901,  p.  37. 


IV.     GENERAL    DISCUSSION    OF    PLASTIC 
OPERATIONS 

CHAPTER-  I 

DIFFERENT   PLASTIC   PROCEDURES 

The  procedures  included  under  plastic  surgery  are  intended  to  cover 
or  repair  deformities  the  result  of  congenital  defects,  disease,  or  accident 
by  the  use  of  living  tissue.  For  hundreds  of  years  surgery  has  found 
in  the  repair  of  defects  of  the  face  by  plastic  operations  one  of  its  prin- 
cipal and  most  satisfactory  tasks.  A  number  of  procedures  have  been 
introduced  and  methods  attempted  to  restore  natural  form  to  parts  of 
the  face  which  have  been  partially  destroyed  or  improperly  formed.  It 
Avould  be  impossible  in  a  book  of  this  character  to  discuss  all  the  dif- 
ferent varieties  of  plastic  operations,  their  good  and  bad  results,  and 
how  they  have  been  modified  to  meet  conditions  arising  during  the  course 
of  an  operation.  In  all  these  operations  with  their  modification  there 
is  a  general  principle  which  makes  it  possible  to  group  the  different 
procedures,  which,  as  a  matter  of  fact,  are  only  varieties  of  the  prin- 
cipal type.     The  following  division  is  probably  the  most  useful : 

1.  Approximation  of  the  edges  of  a  wound  by  "  undercutting  "  them, 
using,  if  necessary,  lateral  liberating  incisions.  This  method,  devised 
by  Celsus,  the  father  of  plastic  surgery,  may  be  modified  in  a  number 
of  ways  in  closing  small  defects.     ' '  Undercutting  ' '  the  edges  of  the 


Fig.  72.  l"'i«-  ";^- 

wound  alone  often  permits  of  complete  closure  of  snuill  oval,  elliptical, 
and  rhomboidal  defects  (Fig.  72), 

The  greater  part  of  a  rectangular  wound  may  be  closed  in  this  way. 
if  the  angles  of  the  wound  are  first  sutured  and  the  long  sides  then 
united  (Fig.  73).  Lateral  liberating  incisions  may  be  made  to  permit 
of  approximation  of  the  edges  of  the  wound,  the  liberating  incision  being 

127 


128 


GENERAL    DISCUSSION    OF    PLASTIC   OPERATIONS 


allowed  to  heal  by  tlie  formation  of  granulation  tissue,  or  being  sutured 
in  the  form  of  an  angular  incision  ( > )  or  a  (Y). 

In  the  Celsus  procedure  proper  the  defect  should  always  be  quad- 
rangular in  shape.     The  edges  of  the  wound  are  mobilized  by  making 


Fig.  74. 

lateral  parallel  incisions  passing  out  from  the  angles.  If  these  incisions 
do  not  permit  of  approximation,  a  semilunar  incision  may  be  made  on 
each  side  at  some  distance  from  the  ends  of  the  lateral  liberating  inci- 
sions.    The  semilunar  incisions  should  only  extend  through  the  cutis, 


-j"j   J^L-C    C 


Fig.  75. 


and  the  concavity  of  the  incision  should  be  directed  toward  the  wound 
(Fig.  75). 

It  can  be  seen  from  the  examples  already  cited  that  this  principle 
may  be  employed  in  a  number  of  different  w^ays  in  closing  differently 
shaped  defects :  for  example,  in  closing  a  quadrangular  defect  lateral 


mmtiwBOTmwp! 


-+4 


f=l-M-=U4=4- 


Fig.  76. 

liberating  incisions  may  be  made  upon  only  one,  upon  two,  or  even 
three  sides.  The  defect  should  be  thought  of  as  composed  of  three  right 
angles,  each  of  which  is  to  be  covered  by  a  mobilized  flap.  In  this  case 
two  of  the  liberating  incisions  pass  from  the  middle  of  the  edge  of  the 
defect  as  represented  in  Figure  76. 


DIFFERENT   PLASTIC   PROCEDURES 


129 


In  triangular  defects  the  liberating  incisions  are  made  along  tlie  line 
of  the  base  of  the  triangle  to  one  or  both  sides  (Fig.  77).  If  necessar}^ 
incisions  as  represented  in  Figures  74  and  75  may  also  be  employed. 


)    )     1     1 


)   M   T  [    C    C 


Fig.  77. 


As  a  rule,  the  edges  of  the  defect  can  be  approximated  much  more 
easily  if  one  or  both  of  the  lateral  incisions  are  curved  (Fig.  78). 

Burow's  method  of  closure  of  triangular  defects  is  very  ingenious, 
but  is  little  employed  at  the  present  time.     It  consists  in  making  lateral 


f  )  )    1 


/ 

Fig.  78. 

incisions,  each  equal  in  length  to  at  least  two  thirds  of  the  width  of 
the  portion  of  the  triangle  to  which  they  correspond.  The  flaps  are  then 
dissected  up  and  approximated  as  indicated  by  the  arrows  in  the  accom- 


panying figures.     The  shape  of  the  wounds  after  suture  is  represented 

at  the  right  hand  side  of  the  figures,  showing  shape  of  defect  (Fig.  79). 

In  narrow  rectangular  defects  a  small  triangular  piece  of  skin  can 

be  excised  upon  the  short  sides  to  permit  of  linear  closure  (Fig.  80a), 


rr)—i — )— i — ^ 


M    )     1     ] 


J 


Fig.  80. 


\ 


or  the  lateral  liberating  incisions  of  Celsus  may  be  combined  with  Bu- 
row's method  as  represented  in  Figure  80  h. 


130 


GENERAL   DISCUSSION   OF   PLASTIC   OPERATIONS 


In  closin<ij  elliptical  defects  an  incision  may  be  made  from  the  middle 
of  one  edge  of  defect  (Lisfranc)    (Fig.  81  a),  and,  if  necessary,  curved 


.-'-'  b 


Fig.  si. 


incisions  may  be  made  upon  both  sides  from  the  extremity  of  this  incision 
(Fig.  81&). 

2.  The  Covering  of  the  Defect  by  Flaps  taken  from  an  Adjacent  Area. 
— There  are  three  different  methods : 

a.  The  lateral  displacement  of  the  flap   (Dieffenhach's  method). 

h.  ''Jumping  a  flap,"  or  torsion  of  tlie  flap  {Indian  method). 

c.  Inversion  and  eversion  of  the  flap. 

a.  The  lateral  displacement  of  a  flap  taken  from  the  area  immediately 
adjacent  to  the  defect  was  devised  by  Dieffenbach,  and  was  first  prac- 
ticed by  him  in  Lisfranc 's  clinic  in  Paris  in  1834:  in  the  formation  of  an 
eyelid  (blepharoplasty). 

The  defect  shonld  be  triangular  in  shape,  and  in  repairing  the  eye- 
lids or  lips  the  base  of  the  triangle  should  correspond  to  the  palpebral 


Fig.  82. 

and  inter] abial  fissures  respectively.  Upon  one  side  of  the  defect  a  rec- 
tangular or  rhomboidal  flap  is  cut  from  the  adjacent  skin  and  dissected 
free  from  the  subjacent  tissues.  The  flap  is  then  displaced,  the  corre- 
sponding sides  of  the  defect  and  flap  being  sutured,  while  the  side  corre- 
sponding to  the  apex  is  not  cut  and  forms  the  bridge  or  pedicle  for 
the  flap  (Fig.  82). 


Fig.  83. 


After  the  flap  is  displaced,  a  triangular  defect  remains,  which  may  be 
diminished  in  size  by  approximating  the  angles  as  represented  in  Figure 
83.    Double  flaps  may  also  be  employed  in  Dieffenhach's  procedure,  then 


DIFFERENT   PLASTIC   PROCEDURES 


131 


the  small  lateral  triangular  defects  reniainin<r  after  displacement  of  the 
flaps  must  be  allowed  to  heal  by  granulation  tissue. 

Elliptical  defects  may  be  closed  by  making  curved  incisions  upon 
one  or  both  sides,  and  forming  tlaps  Avhich  may  be  displaced  into  the 
defect  (Fig.  84  a  after  Hasuer,  and  84  h  after  0.  Weber). 


y^ 


Fig.  84. 


Flaps  which  are  dissected  free  from  the  subjacent  tissues,  but  still 
remain  attached  to  the  surrounding  tissues  at  one  or  both  extremities, 
are  called  pedunculated  tiaps. 

I).  The  "  jumping  "  or  torsion  of  a  flap  corresponds  to  the  old  Indian 
methods  in  which  pedunculated  flaps  from  the  cheek  or  forehead  were 
used  to  repair  nasal  deformities.  This  so-called  Indian  method  first  be- 
came widely  known  through  the  writings  of  Carpue,  an  Englishman,  in 
1816.  After  it  had  been  improved  by  von  Graefe,  it  was  perfected  and 
extensively  employed  by  Dieli'enbach  and  von  Langenbeck. 

In  this  procedure  pedunculated  flaps  of  different  forms  are  made 
from  the  adjacent  skin,  the  pedicle  of  the  flap  being  the  only  part  of  it 
which  borders  immediately  upon  the  defect.  In  order  to  cover  the  de- 
fect the  pedicle  must  be  more  or  less  twisted.  ( If  the  flap  be  not  moved 
more  than  a  quarter  of  a  circle,  twisting  of  the  pedicle  is  not  neces- 
sary, Bryant.)  The  form  of  the  flap  should  correspond  approximately 
to  the  form  of  the  defect.  The  wound  resulting  from  the  separation  of 
the  flap  may  be  diminished  in  size  by  suturing,  or  closed  by  other  pro- 
cedures. 

According  to  Dieffenbach,  one  extremity  of  the  incision  made  in 
forming  the  flap  should  extend  into  the  defect,  as  the  flap  is  mobilized 
better  in  this  way,  and  then  the  pedicle  lies  directly  upon  the  defect,  and 
is  not  separated  from  it  by  a  piece  of  intact  skin  (Fig.  85).  The  other 
extremity  of  the  incision  should  be  curved  somewhat  outward  from  the 
pedicle,  rendering  torsion  of  the  flap  without  tension  possible.  Von 
Langenbeck  laid  great  stress  upon  this  point  in  the  technic. 

If  the  inner  surface  of  the  flap  should  be  covered  with  epithelium, 

as  in  cheiloplasty,  the  flap  should  be  folded  upon  itself  and  the  wound 

surfaces  held  in  approximation  by  sutures. 

c.  The  inversion  or  eversion  of  a  flap  taken  from  the  tissues  imme- 
10 


132  GENERAL   DISCUSSION   OF   PLASTIC   OPERATIONS 

cliately  adjacent  to  the  defect  relates  to  the  employment  of  skin  in  the 
repair  of  mucous  membranes.  For  example,  a  flap  may  be  taken  from 
the  neck,  and  the  surface  of  the  flap  turned  toward  the  mouth  cavity 


Fig.  85. — Displacement  of  Pedunculated  Flap  upon  Pedicle. 

to  take  the  place  of  the  mucous  membrane,  the  cut  surface  of  the  flap 
being  covered  with  Thiersch  grafts.  The  defects  may  also  be  repaired 
by  folding  pedunculated  flaps  upon  themselves,  one  skin  surface  being 
turned  into  the  defect. 

3.  The  covering  of  a  defect  by  pedunculated  flaps  taken  from  distant 
parts  has  its  oldest  prototype  in  the  Italian  procedure.  It,  like  the 
Indian  method,  was  employed  at  flrst  only  for  rhinoplasty.  This  method 
first  became  well  known  through  the  writings  of  Taliacotius  or  Taglia- 
cozza  (1597). 

The  operation  Avas  perfected  especially  by  von  Graefe,  and  there- 
fore it  Avas  known  for  some  time  as  the  German  method.  Flaps  of  dif- 
ferent shapes  are  taken  from  the  arm,  forearm,  or  hand,  and  are  sutured 
into  the  defects,  the  parts  being  immobilized  until  healing  is  com- 
plete.    The  pedicle  of  the  fla]>  may  be  cut,  as  a  rule,  in  about  ten  days. 

In  this  way  defiM-ts  of  the  face  may  be  impaired  with  flaps  from  the 
ann,  of  the  hand  and  arm  with  flaps  from  the  breast,  of  the  foot  and 
leg  with  flaps  from  the  healthy  extremity. 

4.  The  coverirg-  of  defects  with  nonpedunculated  flaps  taken  from  dis- 
tant parts,  (jrafliiiff  or  h-(nis})l(ni((ili()ii  of  skin,  was  probably  attempted 
by  th(!  ancient  Indians.  In  spite  of  repeated  unsuccessful  attempts,  it 
Wfis  tried  again  and  again.  Reverdin's  work,  1869,  in  which  he  trans- 
planted small  pieces  of  skin  from  2  to  6  (jmm.  in  diameter  upon  granu- 
lating surfaces,  prepared  the  way  for  later  studies  and  skin  grafting  as 
it  is  practiced  to-day.  Thiersch  in  1886  perfected  the  method,  obtain- 
ing pcriiiinHMit  healing  by  transplanting  upon  surfaces  from  which  the 
graniilalioi)   tissue  had  been  curetted  away  large  broad  strips  of  epi- 


FUNDAMENTAL   RULES   FOR  PLASTIC   OPERATIONS  133 

dermis  containing  the  stratum  i)apillare.  This  metliod,  beeause  of  its 
simplicity  and  safety,  is  very  extensively  employed.  The  transplanta- 
tion of  cntis  strips  or  flaps  was  promoted  by  the  successfnl  results  ob- 
tained by  von  Buenger  (1823),  "Wolfe,  von  Zehender,  and  von  Langen- 
beck,  and  perfected  by  von  Esmarch  and  Krause. 


CHAPTER    II 

FUNDAMENTAL   RULES   FOR   PLASTIC    OPERATIONS 

These  rules  have  naturally  undergone  many  changes  in  the  course 
of  time.  The  method  of  treating  Avounds  at  the  present  time  has  sim- 
plified these  operations  and  increased  their  safety.  It  is  most  important 
that  the  operation  be  performed  aseptically  and  that  haMiiorrhage  be 
conti'olled,  as  the  healing  of  the  wound  surfaces  will  then  not  be  dis- 
turbed by  suppuration  or  by  the  accumulation  of  blood.  Care  must  also 
be  taken  that  the  blood  supply  of  the  flap  is  good,  as  its  circulation  and 
nutrition  may  be  easily  interfered  with  in  freeing  it,  in  forming  and 
twisting  the  pedicle,  in  suturing,  and  in  applying  dressings. 

Method  of  Separating  the  Flap. — A  flap  which  is  to  be  displaced  or 
twisted  should  be  of  the  same  thickness  throughout.  This  requirement 
may  be  easily  fulfilled  in  the  frontal  and  the  temporal  regions,  in  the 
scalp,  and  in  other  parts  of  the  body,  with  resistant  fascia  and  a  thin 
layer  of  fat.  It  is  more  difificult,  on  the  other  hand,  to  make  a  flap  of  the 
same  thickness  throughout  in  the  fatty  region  of  the  cheek,  as  the  tis- 
sues cannot  be  made  tense  while  it  is  being  dissected  free,  and  the  flap 
is  cut  too  thick  in  one  part,  too  thin  in  another,  and  the  nutrient  vessels 
are  sacrificed.  When  the  incision  has  been  carried  down  to  the  subcu- 
taneous fat,  the  separation  of  the  flap  is  begun  opposite  the  pedicle. 
The  incisions  are  made  vertically  to  the  subcutaneous  tissues,  separating 
the  flap  with  a  thin  or  thick  layer  of  fat  as  far  as  the  pedicle.  In  large 
flaps  a  thick  layer  of  fat  should  be  left  attached  to  the  skin,  as  it  con- 
tains the  blood  vessels  (von  Langenbeck).  The  important  requirement 
regarding  blood  supply  may  be  fulfilled  by  making  the  length  of  the 
flap  correspond  to  the  course  of  the  nutrient  vessel — e.  g.,  arteria  tem- 
poralis, maxillaris  externa.  The  pedicles  of  all  flaps  Avhich  are  to  be 
twisted  should  be  made  narrower  than  the  body  of  the  flap.  The  pedicle 
should,  however,  never  be  narrowei-  than  one  half  of  the  width  of  the  flap. 
In  old  people  it  is  better  to  make  the  pedicle  too  broad  than  too  narrow. 
If  the  pedicle  is  not  mobile  enough  to  permit  of  torsion  of  the  flap  and 


134  GENERAL    DISCUSSION    OF    PLASTIC    OPERATIONS 

covering  of  the  defect  without  tension,  the  extremity  of  the  incision 
which  does  not  end  in  the  defect  should  be  prolonged  outward  (Fig. 
85).    The  pedicle  should  never  be  notched. 

Form  of  the  Flap. — The  form  of  the  flap  should  naturally  correspond 
approximately  to  the  form  of  the  defect.  Flaps  with  long,  pointed  ex- 
tremities should  be  avoided,  because  of  the  danger  of  necrosis.  If  flaps 
are  used  which  correspond  exactly  to  the  size  of  the  defect,  they  will  not 
be  large  enough,  for  the  separated  skin  shrinks  and  tension  will  be  required 
to  approximate  the  edges  of  the  defect  and  of  the  flap.  Von  Graefe 
made  this  mistake  in  his  first  attempts  at  rhinoplasty.  Therefore  the 
flap  must  always  be  broader  and  longer  than  the  defect.  The  length 
of  the  flap  may  be  measured  by  the  fingers,  the  part  forming  the  pedi- 
cle being  the  point  from  which  the  measurement  is  made. 

Sutures  to  be  Employed  and  Method  of  Inserting. — The  sutures  which 
unite  the  borders  of  the  defect  and  flap  should  never  exert  any  tension. 
Fine  silk  (preferably  horsehair)  should  be  used,  and  the  edges  of  the  skin 
should  be  approximated  so  that  the  resulting  scar  will  be  fine.  The 
sutures  should  be  inserted  close  to  the  edge  of  the  skin,  for  sutures 
which  include  nuich  tissue  interfere  with  the  nutrition  of  the  edges,  par- 
ticularly of  the  end  of  the  flap. 

Methods  of  Applying  Bandages. — Poorly  applied  bandages,  producing 
pressure  and  constriction,  also  endanger  the  nutrition  of  the  flap.  Only 
when  the  dressings  are  intended  to  force  the  skin  into  a  cavity — e.  g., 
after  removal  of  contents  of  the  orbit — should  any  pressure  be  exerted. 

In  plastic  operations  upon  the  face  the  dressings  should  be  changed 
frequently,  as  the  skin  about  the  mouth  and  nose  rapidly  becomes  soiled. 
If  a  dressing  is  applied  over  the  eyes,  it  should  be  changed  daily  in 
order  to  prevent  the  accumulation  of  secretion  in  the  space  between  the 
lids  and  the  irritation  of  the  conjunctiva.  The  deepest  layer  of  gauze 
covering  the  line  of  suture  may  be  allowed  to  remain  when  the  dressings 
are  removed  if  there  is  no  infection. 

Eifects  of  Inflammation  and  Venous  Stasis  upon  Flaps. — IMild  inflam- 
mation does  not  interfere  with  the  healing  of  pedunculated  flaps.  Early 
removal  of  the  sutures  h'om  the  suppurating  stitch  holes,  opening  of  the 
line  of  sutui-e,  where  the  exudate  has  accumulated,  ])revents  the  exten- 
sion of  the  inflammation.  If  a  phlegmonous  inflammation  develops,  the 
flap  should  be  raised  and  the  underlying  recesses  should  be  tamponed 
and  drained. 

Frequently  flaps  become  swollen  and  cyanotic  after  they  are  attached, 
and  the  epidermis  may  even  be  separated  by  a  sero-hfemorrhagic  exudate. 
These  changes  are  due  to  passive  congestion,  and  if  the  flap  is  punctured 
in  many  places  the  condition  j-apidly  subsides  in  most  cases.  If  the  flap 
becomes  dark  blue  or  black  in  eolor  it  cannot  be  saved,  and  then  moist 


FUNDAMENTAL   RULES   FOR   PLASTIC   OPERATIONS 


135 


dressings  (witlioiit  rubber  tissue)  should  he  used  ju  hasten  the  separa- 
tion of  the  dead  tissue.  When  the  line  of  deiii.ircation  is  sharply  defined 
tlie  necrotic  tissue  should  be  cut  away. 

Cutting  of  Pedicle. — The  pedicle  may  be  cut  in  from  five  to  ten  days, 
depending  uj^on  the  size  of  the  flap.  In  old  i)eoj)le  it  should  not  be  com- 
pletely divided  at  one  sitting,  but  should  be  divided  at  different  sittings, 
intervals  of  two  or  three  days  intervening.  The  Hap  will  be  pale  for  a 
while  after  each  incision.  The  edges  of  the  divided  pedicle  should  be 
freshened  and  should  be  sutured  in  position  when  divided. 

Technic  of  Skin  Grafting. — Skin  flaps  without  pedicles  demand  a 
special  technic,  depending  upon  whether  epidermal  or  cutis  flaps  are 
employed. 

Epidermal  strips  (Thiersch)  should  be  taken  from  the  ai-m  or  thigh. 
While  the  haemorrhage  of  the  fresh  wound  or  granulating  surface,  vivi- 
fied by  curetting  or  cutting  away  the  granulations,  is  being  controlled, 
the  area  from  which  the  epidermis  is  to  be  taken  should  be  washed  and 
sterilized  as  in  any  other  operation,  and  in  addition  washed  off  with  a  0.9 
per  cent  salt  solution.  The  haemorrhage  from  the  fresh  wound  or  granu- 
lating surface  can  be  controlled  most  easily  by  compression  with  dry 
or  moist  gauze  saturated  with  physiological  salt  solution  or  three  per  cent 
hydrogen  peroxide  solution.  Only  salt  solution  should  come  in  contact 
with  the  epidermal  strips ;  antiseptic  solutions  destroy  the  cells. 

The  skin  should  be  put  on  stretch  before  the  strips  are  cut.  If  the 
epidermis  is  taken,  for  example,  from  the  inner  side  of  the  raised  arm, 


Fig.  86. — Cutting  Grafts;  Traction  Hooks. 


the  assistant  should  stretch  the  skin  toward  the  axillary  fossa  and  the 
operator  toward  the  elbow,  the  razor  or  knife  being  applied  flat  to  the 
skin  near  the  assistant's  hand. 


136 


GENERAL   DISCUSSION   OF   PLASTIC   OPERATIONS 


It  makes  little  difference  what  kind  of  a  knife  is  used,  but  it  nnist 
cut  well  and  be  long  enough.  Broad  and  heavy  knives  with  attached 
handles,  razors  ground  on  the  flat  ^not  hollow  ground),  or  the  ordinary 


Fig.  87.- 


2,  Cutting  Grafts  Without  Traction  Hooks  ;  b,  Placing  Graft  in 
Position. 


razor  may  be  used.  The  author  uses  preferably  a  long,  narrow,  so-called 
phalanx  knife. 

The  skin  is  then  put  on  a  stretch  and  the  epidermal  strips  are  cut 
with  a  sawing  motion.  The  chief  requirement  is  that  the  strip  be  of  the 
same  thickness  throughout.  If  the  strip  is  transparent,  it  is  of  the  proper 
thickness,  for  then  it  must  contain  the  stratum  papillare  with  its  ger- 
minal cells. 

An  experienced  surgeon  can  easily  cut  strips  5  em.  wide  and  20  cm. 
long,  and  the  wound  surface  may  then  be  evenly  covered  with  skin 
grafts.  Ilie  epidermal  strips  should  then  spread  out  upon  the  wound, 
which  no  longer  bleeds,  just  as  a  large  microscopic  section  is  spread  out 
upon  a  slide.  The  strips  should  extend  about  1  cm.  beyond  the  edges  of 
the  defect  in  order  to  become  attached  to  and  cover  them.  If  a  small 
amount  of  blood  accumulates  after  the  strips  are  applied  it  may  be  forced 
out  by  the  slight  pressure  of  scissors  or  other  instruments.  When  the 
strips  are  ])lac('d  upon  a  dry  surface,  agglutination  by  a  thin  layer  of 
fibrin,  which  assists  in  rapid  healing,  occurs  innnediately  (vide  Wound 
Repair,  p.  36). 

Dressing  of  Skin  Crafts.^ — \  dry  dressing  is  the  l)est.  A  layer  oC 
iodoform  gauze  should  be  placed  over  the  grafted  ai'ca,  and  a  few  layers 
of  sterile  gauze  over  this.  Adhesive  plaster  should  then  be  applied  to 
prevent  displacement  ol"  the  dressings.  When  the  dressings  are  changed 
in  from  seven  to  ten  days,  unless  th(>re  are  indications  for  earlier  removal, 
the  lower  layer  of  gauze  should  not  be  removed.  It  forms  a  firm  crust 
with  tlie  wdiiiid  scci'ction,  which,  however,  permits  of  the  escape  of  latter, 
under  which  healing  occurs.  After  the  healing  is  complete  th(>  gauze 
separates  spontaneously.  Ointments  and  moist  compresses  should  not 
be  used,  as  they  macerate  the  epidermal  str'ii)s.    I  can  see  no  advantage  in 


FUNDAMENTAL   RULES   FOR   PLASTIC   OPERATIONS  1.37 

the  open  treatment  of  grafted  wounds  which  is  recommended  by  Briining. 
The  latter  believes  that  the  rapid  drying  of  the  secretion  fnllowitiir  ex- 
posure to  the  air  hastens  agglutination. 

If  suppuration  occurs,  an  attempt  should  be  made  to  save  as  many 
of  the  grafts  as  possible.  If  the  grafts  are  raised  with  tissue  forceps, 
the  underlying  pus  can  be  removed.  Small  white  Islands  of  epithelium 
are  frequently  found  on  granulating  surfaces  from  which  the  epidermal 
strips  have  been  separated  by  suppuration.  If  moist  dressings  which 
clean  the  granulation  tissue  are  applied,  and  the  excessive  granulation 
tissue  is  destroyed  by  cauterization,  these  pieces  of  epithelium  may  pro- 
liferate and  cover  the  defect.  Von  IMangoldt,  guided  by  this  experience, 
has  used  a  simple  method  of  skin  grafting,  which  is  of  advantage  in 
small  granulating  cavities.  IMinute  pieces  of  epidermis  are  shaved  off 
with  a  razor  and  placed  upon  the  vivified  granulating  surface,  after  the 
ha?morrhage  has  been  controlled  (or  upon  healthy  granulating  surfaces), 
the  epithelial  cells  being,  as  it  were,  assimilated. 

The  Thiersch  method  of  skin  grafting  is  often  unsuccessful,  because 
of  the  unhealthy  condition  of  the  granulating  surfaces.  Success  should 
not  be  expected  in  granulating  wounds  following  phlegmonous  inflam- 
mations as  long  as  they  contain  highly  virulent  pyogenic  bacteria  or  the 
resistant  bacillus  pyocyaneus,  as  long  as  they  secrete  profusely,  and  ap- 
pear unhealthy. 

Schnitzler  and  Ewald  have  demonstrated  that  epidermal  strips  may 
heal  upon  nonvivified  granulating  surfaces,  but  the  granulations  must  be 
clean  and  healthy. 

In  old  people  with  flabby  skin,  or  in  small  children,  if  no  material 
is  at  hand,  the  epidermis  from  still-born  children  or  amputated  extremi- 
ties may  be  used  for  grafting. 

If  a  general  anaesthetic  is  not  reciuired  for  some  major  operation, 
local  anaesthesia  may  be  used  for  skin  grafting,  subcutaneous  injec- 
tions in  the  course  of  the  cutaneous  nerves  supplying  the  area,  or  circular 
injections,  according  to  Braun,  being  employed.  Infiltration  anaesthesia 
is  not  suited  for  this  purpose. 

Cutis  Strips. — In  transplanting  flaps  comprising  the  entire  thickness 
of  the  skin,  the  method  described  by  Krause  should  be  employed.  Care- 
ful observance  of  asepsis  and  the  dry  operation  are,  according  to  Krause, 
the  most  important  considerations  next  to  the  complete  control  of  ha'm- 
orrhage.  The  haemorrhage  should  be  controlled  by  the  ligation  of  the 
larger  vessels,  and  by  even  compression  Avith  dry  gauze.  According  to 
the  experience  of  the  author,  the  use  of  three  per  cent  hydrogen  peroxide 
solution  for  rapid  control  of  the  capillary  h:vmorrhage  does  not  injure 
the  tissues. 

The  elements  of  the  transplanted  cutis  degenerate  rapidly,  and  the 


138  GENERAL   DISCUSSION   OF   PLASTIC   OPERATIONS 

flaps  must  be  taken  with  the  greatest  care  to  prevent  more  injury  than 
that  already  produced  by  interference  with  its  nutrition.  Vigorous 
scrubbing,  brushes  and  antiseptics  are  to  be  avoided  in  preparing  the 
field  of  operation. 

The  strip  of  skin,  in  the  form  of  an  elongated  spindle  6  by  20  cm., 
should  be  taken  from  the  thigh  or  arm,  in  children  from  the  back,  and 
the  resulting  defect  closed  by  sutures  after  the  edges  have  been  under- 
cut. If,  as  frequently  is  the  case  in  plastic  operations  upon  the  face 
(to  cover  simultaneously  the  cheek,  temporal  region,  or  adjacent  parts 
of  the  neck),  flaps  the  size  of  the  hand  and  corresponding  to  the  form 
of  the  defect  are  required,  the  resulting  wound  should  be  covered  at  once 
with  epidermal  strips. 

In  preparing  the  cutis  strips,  Krause  directed  all  the  incisions  against 
the  cutis,  so  that  the  strip  when  free  contained  no  fat.  Von  Esmarch 
removed  the  skin  and  a  layer  of  subcutaneous  fat,  and  then  spread  it 
out  upon  the  hand  with  the  fat  upward,  and  cut  away  the  fat  with  a 
pair  of  curved  scissors.  Hirschberg  has  demonstrated  that  flaps  con- 
taining subcutaneous  fat  will  heal,  but,  as  a  rule,  they  have  no  advan- 
tage. In  parts  of  the  face  where  the  least  contraction  of  the  flap  pro- 
duces distortion  (about  the  eyelids)  the  author  uses  by  preference  flaps 
containing  a  thin  layer  of  fat,  as  they  become  softer  and  more  movable 
cutis  than  without  fat. 

In  making  a  cutis  flap  it  should  be  remembered  that  after  it  is  cut 
it  shrinks  and  becomes  smaller. 

If  the  wound  to  be  grafted  is  not  yet  dry  after  the  flap  is  cut,  the 
latter  should  be  folded  so  that  tlie  raw  surfaces  are  in  contact,  further 
injury  of  the  flap  being  prevented  in  this  way.  The  flaps,  when  applied 
to  the  wound  surface,  become  so  tightly  agglutinated  by  the  fibrin  layer 
that  they  appear  to  be  glued  together.  Agglutination,  which  is  pre- 
vented by  the  slightest  ha'morrhage,  is  an  important  factor  in  the  healing 
process.  The  edges  of  the  defect  and  flap  should  be  closely  and  accu- 
rately approximated.  Sutures  as  a  rule  can  be  dispensed  Avith,  and  as 
they  exert  tension,  are  not  to  be  advised. 

The  dressings,  as  previously  described  in  discussing  the  technic  of 
epidermal  grafting,  may  be  employed. 

Tlie  flap  appears  cyanotic  after  a  few  days,  and  its  epidermis  ])e- 
comes  separated.  If  some  parts  of  the  graft  die,  they  dry  under  aseptic 
treatment,  and  are  finally  cast  ofi'  by  granulation  tissue.  If  after  ten 
days  the  greater  part  of  the  flap  is  reddish  and  warm,  moist  dressings 
may  be  applied  to  hasten  the  separation  of  the  necrotic  areas. 

Tnflatniiiation  i)revents  complete  healing.  If,  however,  the  flaps  have 
become  firmly  attached  aftei-  a  few  days,  they  withstand  severe  inflam- 
mations, as  no  exudate  is  foiiiied  beneath  them. 


PLASTIC   OPERATIONS  WITH   COMPOUND   FLAPS  139 

Use  of  Toes  to  Replace  Fingers. — Concerning  the  healing  of  trans- 
planted pieces  of  skin,  vide  Wound  Healing. 

Nicoladoni's  procedure  of  using  the  tip  of  a  toe  with  a  nail  to  cover 
the  bony  stump  of  an  index  finger  which  had  been  pai'lly  toi'u  away 
comes  under  the  head  of  skin  grafting. 

Epidermal  strips  have  the  advantage  of  surety  and  rapidity  of  heal- 
ing. Cutis  strips,  on  the  other  hand,  are  more  resistant,  shrink  less, 
and  give  better  cosmetic  results.  On  the  face  and  parts  of  the  body  fre- 
quently exposed  to  trauma,  such  as  the  palm  of  the  hand  and  the  ante- 
rior surface  of  the  leg,  the  cutis  strips  are  to  be  preferred  for  grafting. 
Where  the  quick  covering  with  skin  of  a  granulating  surface  is  desired, 
as  after  extensive  burn,  and  where  shrinkage  of  the  grafted  area  is  of 
no  great  significance,  or  it  does  not  occur,  as  on  the  forehead,  epidermal 
strips  should  be  employed. 


CHAPTER    III 

PLASTIC    OPERATIONS    VS'ITH    COMPOUND    FLAPS,    AND    TRANSPLANTATION    OP 
MUCOUS    MEMBRANE,    CARTILAGE,    AND   BONE 

The  pedicle  which  provides  nourishment  for  and  insures  the  via- 
bility of  the  pedunculated  skin  tla})s  permits  also  of  the  use  of  deeper 
lying  tissues,  such  as  mucous  membrane,  cartilage,  and  bone  for  the 
repair  of  defects. 

In  the  Dieffenbach  procedure  (1834),  employed  in  a  number  of  dif- 
ferent ways  to  repair  the  lips  (cheiloplasty),  the  mucous  membrane  is 
transferred  with  the  skin  flap  to  form  the  red  margin  of  the  lip  and  its 
inner  lining.  If  cnly  a  small  area  of  mucous  membrane  is  lost,  a  flap 
consisting  of  mucous  membrane  only  is  required. 

Compound  Flaps. — Compound  flaps  are  used  most  frequently  to  repair 
bony  and  cartilaginous  defects.  The  studies  of  von  Langenbeck  con- 
cerning the  value  of  the  periosteum  for  plastic  purposes  resulted  in  the 
introduction  of  his  operation  for  the  repair  of  cleft  palate  (uranoplasty, 
1861),  which  is  used  as  originally  devised  by  him  even  at  the  i)resent 
time.  Two  pedunculated  flaps,  consisting  of  mucous  membrane  and  peri- 
osteum, are  freed  from  the  palatal  processes  of  the  umxilLn?  and  united 
to  cover  the  defect  in  the  palate.  The  layer  of  bone  formed  in  these 
eases  is  thin  but  sufficient.  The  skin-periosteal  flaps  taken  from  the  fore- 
head to  repair  nasal  defects  (von  Langenbeck's  periosteal  rhinoplasty) 
are  unreliable  and  insufficient  as  far  as  the  formation  of  bone  is  concerned, 
and  have  been  replaced  by  the  skin-periosteal-osteal  flaps.     As  early  as 


140  GENERAL   DISCUSSION   OF   PLASTIC   OPERATIONS 

1855  Langenbeck  had  thought  that  it  might  be  of  advantage  to  remove 
a  thin  layer  of  bone  with  the  skin  and  periosteum  in  performing  rhino- 
plasty, but  he  desisted  "  because  resection  of  the  external  table  would 
open  the  veins  of  the  diploe  and  phlebitis,  and  suppurative  meningitis 
might  follow  this  injury."  Konig  in  1866  was  the  first  who  attempted 
to  perform  a  rhinoplasty  of  this  kind.  The  attempt  was  success- 
ful, and  the  foundation  for  a  great  number  of  operations  was  laid. 
The  skin-periosteal-osteal  flap  or  cortical  bony  flap  (Konig)  is  formed  in 
the  following  way:  When  the  skin  is  cut  it  is  not  raised  from  the  sub- 
jacent periosteum,  but  a  chisel  is  inserted  and  a  thin  plate  of  the  ex- 
ternal bony  layer  which  remains  attached  to  the  periosteum  is  raised. 
The  pedicle  should  contain  no  bone,  as  it  would  interfere  with  turning 
the  flap.  The  entire  flap,  composed  of  skin,  periosteum,  and  bone,  is  then 
twisted  or  displaced  into  the  defect,  which  has  previously  been  vivified; 
ossification  occurs,  and  the  defect  is  repaired.  Skin  sutures  are  suf- 
ficient to  maintain  the  flap  in  position.  If  the  piece  of  bone  is  separated 
from  the  periosteum  by  the  chisel,  it  can  be  placed  in  the  defect  and  cov- 
ered with  the  flap  of  skin  and  periosteum  {vide  Transplantation  of  Bone) . 

This  procedure  has  been  used  extensively  in  a  number  of  ways:  for 
rhinoplasty,  for  covering  defects  in  the  skull  (Konig  and  AV.  Mueller), 
for  filling  in  and  repair  of  pseudarthroses  (W,  ]\Iueller  and  von  Eisel- 
berg),  and  for  the  transplantation  of  small  bones  and  of  entire  segments 
of  bone. 

It  is  possible,  e.  g.,  to  use  a  pedunculated  flap  of  the  forearm,  in- 
cluding a  piece  of  the  ulna,  to  form  a  nose  according  to  the  Italian 
method  (Israel).  The  two  distal  phalanges  of  the  finger  may  be  replaced 
by  those  of  the  toe  by  a  method  introduced  by  Nicoladoni.  In  this  opera- 
tion a  ({uadrilateral  flap,  the  base  of  which  is  directed  forward,  is  raised, 
and  the  extensor  tendons  and  the  joint  (the  interphalangeal  or  meta- 
carpo-phalangeal  of  one  or  two  toes  depending  upon  the  case)  and  the 
flexor  tendon  are  divided.  The  skin  upon  the  plantar  surface  remains 
attached  and  forms  the  pedicle.  The  toes  are  then  attached  to  the  vivified 
stump  of  the  finger  by  skin,  tendon,  and  bone  sutures,  and  both  extremi- 
ties are  immobilized  in  plaster  of  Paris  dressings  to  prevent  tension  upon 
the  pedicle,  which  is  divided  in  about  two  weeks. 

The  following  are  examples  of  the  different  Avays  in  which  skin- 
periosteal-osteal  flaps  have  been  used  in  plastic  surgery:  Flaps  from  the 
sternum  (Schimmelbusch)  or  clavicle  (Konig)  have  been  used  to  repair 
tracheal  defects.  Fritz  Kiinig  has  used  for  the  same  purpose,  with  suc- 
cess, a  compound  flap,  the  cartilage  being  taken  from  the  thyroid  car- 
tilage. 

Osteoplastic  operations  rcs('iiil)le  closely  j)l;isli('~()p(M"itions  with  com- 
pound flaps.     In  lliese  cases  a  layer  of  bone  which  retains  its  connection 


PLASTIC    OPERATIONS   WITH   COMPorXD    FLAPS  141 

with  the  soft  parts  is  elevated,  aud  after  the  completion  of  the  operation  it 
is  replaced  in  the  area  which  it  formerly  occupied  (osteoplastic  resection 
of  the  skull,  Wagner;  osteoplastic  resection  of  the  maxilla,  von  Langen- 
beck;  of  the  nose,  Oilier  and  von  Bruns;  the  external  wall  of  the  orbit, 
Kronlein;  the  zygoma  for  different  operations  upon  the  trigeminal 
nerve).  Sometimes  parts  of  neighboring  bones  are  retained  in  ampu- 
tations and  resections,  and  are  displaced  with  the  soft  tissues  attached 
to  them  to  cover  the  ends  of  sawn  bones  (Pirogoff's  osteoplastic  exarticu- 
lation  of  the  foot,  using  part  of  the  os  calcis  to  cover  tlie  sawn  surfaces 
of  the  tibia  and  fibula;  von  INlikulicz-Wladimirow's  resection  of  the  foot, 
using  the  anterior  part  of  the  foot  in  a  similar  way;  Cn-itti's  amputation 
of  the  thigh,  transplanting  the  sawn  patella  to  the  femur). 

There  are  a  number  of  different  procedures  which  nuiy  be  employed 
to  repair  small  bony  defects,  being  intermediate  between  the  peduncu- 
lated skin-bone  flaps  and  the  direct  transplantation  of  l)one.  In  these  a 
layer  of  bone  is  raised  which  remains  connected  with  the  periosteum,  the 
latter  forming  the  pedicle,  about  which  the  layer  of  bone  is  twisted  (ftu- 
repair  of  saddle-nose,  amputation  of  the  lower  extremit.y  by  Bier's  method 
to  obtain  a  more  useful  stump). 

The  transplantation  of  mucous  membrane  is  especially  useful  to  re- 
place the  conjunctiva  palpebral  in  the  formation  of  lids  (lilepharoplasty). 
The  mucous  membrane  may  be  taken  to  the  best  advantage  from  the 
lips  and  cheeks.  In  blepharoplasty  a  pedunculated  flap  of  skin  is  flrst 
transplanted,  and  after  the  flap  has  healed  in  position  the  nnicous  mem- 
brane is  grafted  (vide  p.  47).  The  same  technic  is  employed  in  grafting 
mucous  membrane  as  in  grafting  skin. 

Chips  and  plates  of  bone  have  been  taken  from  the  anterior  surface 
or  crest  of  the  tibia  to  fill  in  a  defect  in  the  skull  (Seydel),  to  fill  in 
a  sunken  nasal  bridge,  and  to  repair  a  pseudarthrosis  (^langoldt). 

The  purposes  for  which  cartilage  may  be  transplanted  have  Ixuni  pre- 
viously mentioned. 

Transplantation  of  bone  has  been  employed  extensively;  results  are 
more  certain  when  fresh,  living  material  is  used.  Bone  chips  and  fi-ag- 
ments,  longitudinally  divided  long  bones,  or  resected  pieces  of  the  latter 
may  be  used. 

The  metatarsal  bones,  the  bones  of  the  forearm  and  leg,  have  been 
longitudinally  divided  and  used  by  Bardenheuer  to  repair  defects  in 
neighboring  bones  (Cramer). 

Resected  pieces  of  bone  from  the  patient  or  from  an  extremity  which 
has  been  recently  amputated,  may  be  used  to  repair  a  defect  in  another 
bone.  Bergmann  transplanted  a  piece  of  the  fibula  12  cm.  long  into  a  de- 
fect in  the  tibia,  following  a  resection  for  a  sarcoma.  The  piece  of  the 
fibula  was  maintained  in  position  by  silver  wire  sutures.    The  soft  tissues 


142  GENERAL   DISCUSSION   OF   PLASTIC   OPERATIONS 

must  all  be  removed  from  the  bone,  which  is  to  be  employed  for  transplan- 
tation, and  the  latter  must  be  thoroughly  cleaned  and  boiled.  Asepsis 
and  the  control  of  hajmorrhage  are  most  essential  factors  in  the  success 
of  bone  transplantation.  The  transplanted  bone  should  be  maintained 
in  position  by  sutures  whenever  displacement  is  likely  to  occur. 

The  advantages  of  the  transplantation  of  bone  as  compared  to  the 
use  of  pedunculated  skin-periosteal-osteal  flaps  are  these:  Larger  frag- 
ments of  bone  may  be  used,  and  the  large  scars  following  the  use  of  flaps 
— e.  g.,  in  the  face — are  avoided.  If  the  transplantation  is  not  success- 
ful, it  may  be  tried  again,  or  the  more  reliable  skin-periosteal-osteal  flap 
may  be  employed. 


PART   II 

WOUJN-D    INFECTIONS    AND    SURGICAL 
INFECTIOUS    DISEASES 


I.    THE    NATURE   OF    INFECTION;    THE    LOCAL 
AND    GENERAL    REACTION 

CHAPTER    I 

THE    NATURE    OF    INFECTION 

If  materials  from  without  which  injure  the  tissues  gain  access  to  a 
wound,  the  latter  is  regarded  as  contaminated  or  infected.  A  wound 
infection  may  be  caused  by  poisonous  substances  such  as  snake  venom, 
as  well  as  by  bacteria,  and  therefore  a  purely  toxic  is  differentiated  from 
a  purely  bacterial  infection.  The  bacterial  are  so  much  more  frequent 
than  the  toxic  infections  that  the  term  has  practically  been  limited  to 
the  former,  and  when  a  wound,  the  field  of  operation,  and  the  hands  are 
spoken  of  as  infected,  the  term  is  employed  in  this  sense. 

Toxic  Wound  Infections. — In  toxic  wound  infections  the  poisons  enter 
the  circulation  and  produce  a  general  toxic  infection  (e.  g.,  snake 
venom ) . 

Bacterial  Wound  Infections. — Bacterial  wound  infections  may  be  fol- 
lowed by  general  infections,  but  these  are  not  pure  general  bacterial  infec- 
tions, for  toxins  are  produced  by  bacteria  when  they  grow  in  the  tissues, 
and  are  liberated  when  they  die  and  are  dissolved,  and  in  these  general  in- 
fections the  organism  is  flooded  not  only  with  the  bacteria,  but  with 
their  toxic  products  as  well.  Sometimes  in  the  general  bacterial  infec- 
tions the  most  marked  symptoms  are  produced  by  the  presence  and  mul- 
tiplication of  the  bacteria  in  the  blood  stream  and  viscera,  while  in  other 
cases  they  are  due  to  the  absorption  of  the  toxins  from  the  primary 
focus,  few,  if  any,  bacteria  being  found  in  the  blood  and  viscera. 
Theoretically  a  general  bacterial  and  a  general  toxic  infection  may  be 
differentiated  from  each  other,  but  practically  it  is  not  always  possible 
to  dift'erentiate  between  the  two.  Tetanus,  diphtheria,  and  many  diseases 
caused  by  pyogenic  and  putrefactive  bacteria  are  toxic  infections,  as  the 

143 


144       NATURE   OF   INFECTION;   LOCAL   AND   GENERAL   REACTION 

action  of  the  toxins  elaborated  by  the  bacteria  found  in  these  diseases 
gives  to  the  latter  their  most  essential  characteristics.  In  most  infections 
with  pyogenic  bacteria,  in  anthrax  and  plague  infections,  the  micro- 
organisms invade  and  multiply  in  the  blood  and  are  deposited  (metas- 
tases) in  tissues  (glanders,  leprosy,  miliary  tuberculosis)  producing  the 
most  prominent  symptoms  of  the  diseases. 

The  general  putrefactive  infections  are  frequently  general  toxic  in- 
fections (sapra^mia),  developing  secondary  to  putrefactive  wounds  from 
which  the  products  elaborated  by  the  putrefactive  bacteria,  only  rarely 
the  bacteria  themselves,  are  absorbed. 

Because  of  the  similarity  of  the  general  clinical  symptoms  occurring 
in  the  general  putrefactive,  toxic,  and  bacterial  infections,  the  term 
sepsis  or  septicaemia  has  been  applied  to  all  general  infections  caused 
by  pyogenic  bacteria.  Bacteriologists,  following  Koch's  example,  regard 
any  infection,  regardless  of  the  micro-organism  (pyogenic  cocci,  plague 
bacilli,  or  the  plasmodium  of  malaria),  as  septicemia  if  the  bacteria 
invade  and  multiply  in  the  blood.  [In  the  German  edition  of  this  book 
the  terms  sepsis,  septicaemia,  pyiemia,  and  a  number  of  different  terms 
which  have  been  applied  to  mixed  forms  of  general  infection,  are  not 
used.  Lexer  describes  a  general  pyogenic  infection  without  metastases, 
a  general  pyogenic  infection  with  metastases,  and  a  general  putrefactive 
infection.  The  words  septicemia,  pyaemia,  and  sapra-mia  have  become  so 
well  established  in  American  medical  literature  that  it  seems  best  to  use 
them  in  conjunction  with  the  terms  used  by  Lexer.  To  be  sure,  the 
terms  have  been  used  differently,  and  even  at  the  present  time  are  inter- 
preted differently  by  dift'erent  authorities.  Pyemia  is  synonymous  with 
general  pyogenic  infections  with  metastases,  septicemia  with  general  pyo- 
genic infections  without  metastases,  and  sapramiia  with  general  putre- 
factive infections.] 

Monoinfections,  Polyinfections,  Reinfections. — Besides  the  simple 
infections  (monoinfections),  which  are  caused  by  one  variety  of  micro- 
organism, there  are  the  mixed  infections  (polyinfections)  which  are 
caused  by  two  or  more  varieties  of  bacteria  acting  simultaneously. 
Later  infection  with  another  variety  of  micro-organism  is  called  second- 
ary or  accessory  infection.  If  infection  occui-s  later  with  the  same 
variety  of  mici-o-organisni  as  produced  the  first  infection  it  is  called 
new  or  reinfection. 

Causes  of  Inflammation. — From  a  surgical  view  point  the  most  im- 
portant canses  of  inihunmation  are  of  a  plant  natui'e;  almost  all  belong 
1()  the  class  of  bacteria.  These  are  simple  cells  which  multiply  by  fission, 
and   For  lliat  reason  ai'e  called  fission-fungi  or  scliizomycetes. 

Action  of  Bacteria,  Toxins,  and  Endotoxins. — Their  action  depends 
cliielly  ui)on  toxic  materials,  which  are  produced  by  them  in  the  tis- 


THE   NATURE   OF   INFECTION  145 

sues  just  as  tlicy  arc  upon  artificial  iiic(lia.  Tlif  mcclianical  action  of 
bacteria,  such  as  is  produced  by  the  ])lu.i;iiiu^'  oL'  capillaries  wlien  hir<re 
numbers  circulate  in  the  blood,  is  of  much  less  moment  than  was  for- 
merly considered  to  be  the  case  before  we  had  accurate  knowledge  of 
the  formation  of  toxins  and  the  action  of  bacteria.  Bacteria  do  not 
develop  in  large  enough  numbers  to  have  any  great  mechanical  action. 
No  soluble  toxin  characteristic  of  the  anthrax  bacillus  has  been  demon- 
strated, and  it  may  be  possiiile  that  in  this  infection  the  large  number  of 
bacilli  circulating  in  the  blood  have  a  mechanical  action  in  closing  the 
capillaries.  If  so,  this  is  the  only  infectious  disease  in  which  mechanical 
occlusion  is  the  chief  factor. 

The  poisonous  materials  produced  by  bacteria  are  in  general  of 
two  kinds:  sometimes  one  predominates,  sometimes  the  other.  These 
materials  are  produced  by  the  action  of  the  bacteria  upon  the  tissues  or 
upon  culture  Huids  in  which  they  are  soluble,  and  are  to  be  regarded  as 
secretion  products  of  bacteria.  If  a  culture  of  bacteria  which  produces 
large  amounts  of  poisons  such  as  the  tetanus  or  diphtheria  bacillus  is 
made,  and  the  culture  is  then  passed  through  a  porcelain  filter  which  is 
not  permeable  to  the  bacilli,  the  filtrate  if  injected  into  animals  will 
produce  the  same  symptoms  as  those  produced  by  the  bacteria,  while  the 
bacterial  residue  has  no  action.  The  filtrate  therefore  contains  poison- 
ous materials  which  have  been  produced  in  the  culture  media.  These  poi- 
sonous secretion  products  of  bacteria  are  called  toxins.  Their  chemical 
nature  is  not  fully  understood.  Apparently  they  do  not  belong  to  the 
albumins  proper,  although  they  are  closely  related  to  them  and  to  the 
ferments.  They  are  extremely  sensitive  to  chemical  influences,  particu- 
larly so  to  heat,  and  lose  their  toxic  action  immediately  when  heated  to 
80°  C.  and  in  a  short  time  after  being  heated  to  50°  C.  Their  chief  char- 
acteristic is  their  specificity,  all  toxins  having  a  definite  specific  action 
corresi)onding  to  that  of  the  bacteria  by  which  they  are  secreted.  The 
toxins  of  many  bacteria  (streptococci,  staphylococci,  bacillus  pyocyaneus, 
bacillus  of  tetanus)  contain  bodies  which  dissolve  (luvmolysins)  or  agglu- 
tinate (agglutinins)  red  corpuscles.  Experiments  have  demonstrated 
that  haemolysis  and  agglutination  are  due  to  different  substances. 

The  second  variety  of  bacterial  poisons  are  the  bacterial  protoplasmic 
poisons.  They  are  the  substances  which  are  contained  within  the  proto- 
plasm of  the  bacteria,  and  are  liberated  only  when  the  bacteria  die  and 
are  dissolved.  Buchner  named  the  albuminous-like  i>oisons  which  are  ob- 
tained when  cultures  are  boiled  or  ground  up,  bacterial  proteins.  Their 
action  when  the  bacterial  protoplasm  contains  no  true  toxin  (endotoxin) 
is  not  specific.  They  have  a  common  action  which,  as  a  rule,  is  pyogenic 
(Oppenheimer).  The  action  of  the  proper  pyogenic  bacteria  or  micro- 
organisms depends  upon  the  toxins  produced  by  them  and  endotoxins 


146       NATURE   OF   INFECTION;   LOCAL   AND   GENERAL   REACTION 

which  are  freed  when  bacteriolysis  occurs.     The  results  of  bacterial  in- 
fection of  a  wound  are  twofold — local  and  general. 


CHAPTER    II 

LOCAL    REACTION 

The  local  reaction  begins  Avith  the  entrance  of  the  bacteria  into  the 
tissues  (invasion).  It  does  not,  however,  follow  immediately  the  inva- 
sion, as  the  bacteria  must  first  become  adapted  to  their  new  surround- 
ings, and  must  develop  to  such  an  extent  that  the  bactericidal  proper- 
ties of  the  tissues  can  no  longer  restrain  their  growth.  The  length  of 
the  period  of  incubation  varies,  depending  upon  the  number  and  viru- 
lence of  bacteria  and  the  resistance  of  the  organism.  It  is  of  only  a  few 
hours'  duration  when  the  bacteria  are  derived  from  a  patient  with  a 
severe  infecti(m  (e.  g.,  general  pyogenic  infection,  meningitis,  perito- 
nitis, phlegmon).  It  is  longer — according  to  Friedrichs's  experiments  at 
least  six  hours  for  the  bacillus  of  malignant  oedema — when,  as  is  usually 
the  case,  the  bacteria  come  from  the  outer  world.  Bacteria  of  a  low  grade 
of  virulgnce  frequently  are  unable  to  invade  the  tissues,  as  their  growth 
is  prevented  by  the  bactericidal  properties  of  the  tissue  fluids. 

Bacterial  toxins  destroy  the  tissues,  but  they  also  irritate  them  and 
incite  a  number  of  processes  which  are  intended  to  defend  the  tissues 
against  their  invasion.  The  more  active  the  defense  the  more  violent 
the  local  reaction.  The  usual  local  reaction  may  be  absent  if  a  weakened 
organism  is  attacked  by  highly  virulent  bacteria,  as  in  such  a  case  as 
this  a  powerful  defense  would  not  be  possible.  In  experimental  work 
there  is  no  local  reaction  when  the  organism  has  previously  been  im- 
munized against  the  bacteria  in  question;  there  being  no  necessity  for 
defense,  as  the  protective  bodies  which  will  not  permit  of  the  develop- 
ment and  invasion  of  the  bacteria  are  already  present  in  large  quantities. 

The  local  reaction  is  inflammatory  in  character  and  varies  in  char- 
acter and  degree.  It  differs  even  with  the  same  infection,  and  depends 
upon  a  number  of  factors,  especially  upon  the  virulence  of  the  bacteria 
and  the  resistance  of  the  tissues.  In  many  cases  the  local  reaction  is  char- 
acteristic, giving  to  the  infection  distinct  clinical  features.  Strepto- 
cocci from  the  same  source  may  produce  a  serous,  a  fibrinous,  or  a 
suppurative  inflannnation.  The  local  reaction  produced  by  pyogenic 
cocci,  diphtheria  and  tubercle  bacilli  is  very  difl'erent.  In  a  purely  toxic 
infection  the  general  symptoms  are  produced  by  the  absorption  of  the 
toxins,  and  the  local  changes  have  nothing  characteristic — e.  g.,  tetanus. 


LOCAL   REACTION 


147 


Inflammatory  processes  are  characterized  by  three  fuiKhimental 
changes,  notwithstanding  their  different  elinic^al  pictures.  The  changes 
are  not  only  incited  by  bacterial  toxins,  but  also  by  mechanical,  thermal, 
and  chemical  irritation.  [At  the  present  time  the  changes  produced  by 
mechanical,  thermal,  and  chemical  irritation  are  regarded  as  reparative 
rather  than  as  intiammatory.]      The  three  processes  are: 

1.  Disturbance  of  circulation  Avith  exudation. 

2.  Degenerative  changes. 

3.  Regenerative  changes. 

1.  Disturbance  of  Circulation  with  Exudation. — The  vascular  changes 
may  be  most  easily  followed  when  the  mesentery  of  a  frog  or  rabbit  is 
spread  out  upon  a  glass  slide  and  observed  under  a  microscope.  In  this 
way  the  mesentery  is  exposed  to  the  desiccating  influence  of  the  air  and 
the  irritating  substances  in  it,  and  inflammatory  processes  are  incited. 
The  vascular  changes  begin  with  an  active  (congestive)  hyperemia,  as 
the  irritation  paralyzes  the  vasoconstrictors  and  the  vessel  walls  become 


Fjg.  88. — Section  of  Infi,amed  Omentum  from  Man.  (After  Ziegler.)  a,  Normal  traho- 
culiB  in  omentum;  b,  normal  endothelium;  c,  small  artery;  /,  detachetl  endothelium; 
/,  polynuclear  cells;   g,  extravasated  red  blood  corpuscles. 


relaxed.  The  blood  flows  more  rapidly  tbrough  the  arteries,  capillaries, 
and  veins.  Soon,  however,  there  is  a  marked  slowing  of  the  blood  stream 
in  the  center  of  the  inflammatory  focus,  and  a  passive  hypertrmia  suc- 
ceeds the  active,  as  the  injured  vessel  walls  offer  more  resistance,  become 
11 


148       NATURE   OF   INFECTION;   LOCAL   AND   GENERAL   REACTION 

more  permeable,  and  the  siirroiinding  tissues  lose  their  tension.  Often 
there  is  a  transitory  stagnation  of  the  blood  stream  in  the  capillaries 
(stasis). 

Migration  of  Leucocytes. — A  peripheral  stasis  of  the  leucocytes  in 
the  veins,  and  their  accumulation  in  the  capillaries  precedes  the  exu- 
dation. As  soon  as  the  blood  stream  begins  to  slow,  the  leucocytes  pass 
to  the  peripheral  portion  of  the  blood  current,  which  ordinarily  is  com- 
posed of  plasma  containing  no  cells.  The  heavier  red  blood  corpuscles 
remain  in  the  center  of  the  stream.  Slowly  the  leucocytes  roll  along  the 
vessel  wall,  until  single  cells  or  whole  groups  of  them  become  at- 
tached. This  occurs  nnich  more  readily  in  the  capillaries,  M'here  there 
is  often  stagnation  of  the  blood  stream.  Then  follows  the  emigration 
of  the  leucocytes,  which  has  been  described  by  Cohnheim.  Just  as  an 
oil  drop  swimming  upon  water  changes  its  form  when  small  parts  are 
sent  out,  and  assumes  its  form  again  when  these  flow  back,  so  the  motile 
protoplasm  of  the  leucocytes  sends  out  narrow  pseudopodia  through  the 
vessel  wall  where  the  cement  lines  of  the  endothelium,  which  under  nor- 
mal conditions,  and  still  more  so  when  the  vessel  wall  is  injured,  offer 
a  point  of  exit.  When  the  entire  leucocyte  has  passed  through  the  vessel 
wall,  it  begins  to  wander  into  the  tissues. 

CJiemotaxis:  Positive  and  Negative. — This  active  passage  of  the  leu- 
cocyte from  the  vessel  wall  is  due  to  the  attractive  action  of  the  cause 
of  the  inflammation.  This  property  of  leucocytes  and  almost  all  motile 
cells  of  being  attracted  by  definite  chemical  substances,  particularly  by 
most  bacterial  toxins  and  proteins,  is  called  positive  chemotaxis  {vide 
Leucocytes,  p.  159).  Some  bacteria,  such  as  the  bacillus  of  anthrax  and 
malignant  oedema,  repel  the  leucocytes,  this  phenomenon  being  called 
negative  chemotaxis. 

Formation  of  the  Exudate. — "While  leucocytes  wander  into  the  inflam- 
matory focus  from  all  sides  and  infiltrate  the  tissues,  so  that  their  struc- 
ture can  no  longer  be  recognized,  an  exudate  is  being  poured  out  from 
the  vessels  which  separates  the  tissues  and  fills  the  tissue  spaces.  The 
pouring  out  of  the  exudate,  which  is  to  be  regarded  as  a  product  of 
secretion  rather  than  of  filtration  (Heidenhain),  is  due  to  an  alteration 
of  the  vessel  wall,  in  consequence  of  which  the  secretory  function  of 
the  endothelium  is  altered.  The  injured  vessel  wall  becomes  more  per- 
meable than  normal,  so  that  materials  which  usually  remain  in  the  blood 
are  no  longer  retained.  The  inflammatory  exudate  differs  from  lymph 
in  that  it  contains  greater  numbers  of  cells  and  larger  amounts  of 
albumin.  As  a  result  of  the  exudate  the  hypersemic  area  becomes  tense 
and  hard  (inflammatory  infiltrate)  or  presents  the  signs  of  oedema  (in- 
flainmatory  fedema),  as  it  pits  when  pressure  is  made  with  the  finger. 

Im[)ortant  provisions  for  the  protection  of  the  tissues  are  combined 


LOCAL  REACTION  14!) 

with  these  changes.  In  the  non-bacterial  inflaniniations  the  liquefaction 
of  the  necrotic  tissue  which  renders  absorption  possil)le  is  the  first  pro- 
tective step.  The  cellular  exudate  forms  the  first  line  of  defense  against 
bacteria,  as  it  contains  bactericidal  bodies  which  are  ably  supported  in 
their  action  by  the  leucocytes  (phagocytes). 

Polymorphonuclear  Leucocytes,  Plasma  Cells,  etc. — The  cells  which 
emigrate  from  the  vessels  are  mostly  polymorphonuclear  leucocytes  with 
neutrophile  granules,  which,  according  to  Ehrlich,  are  derived  chiefly 
from  the  bone  marrow.  If  the  vessel  wall  is  severely  damaged,  red  cor- 
puscles which  have  escaped  by  diapedesis  or  rhexis,  and  other  varieties 
of  leucocytes,  such  as  lymphocytes  and  eosinophilous  leucocytes,  the 
granules  of  which  stain  Avith  acid  dyes,  are  found.  The  lymphocytes  are 
small,  round,  motile  cells  with  large  nuclei.  They  lie  together  in  small 
groups  (so-called  small  cell  infiltration)  and  Ribbert  is  of  the  opinion 
that  they  form  a  small  lymphatic  focus,  particularly  in  the  neighbor- 
hood of  the  vessels,  w^hicli  increases  as  the  inflammation  progresses,  and 
because  they  are  intended  to  absorb  noxious  materials  they  remain  for 
a  long  time. 

2.  Degenerative  Changes. — The  degeneration  and  necrosis  within 
the  inflammatory  focus  is  partly  due  to  the  bacterial  toxins,  to  mechani- 
cal, chemical,  and  thermal  influences — all  of  which  act  upon  the  cells  and 
frequently  cause  their  death.  They  are  also  partly  due  to  circulatory 
and  nutritional  disturbances  resulting  from  the  pressure  of  the  exudate, 
the  stasis  in  the  capillaries,  and  the  thrombosis  of  inflamed  veins  and 
arteries  {vide  Pyogenic  Disease  of  the  Vessels,  p.  238). 

The  necrotic  tissues  become  liquefied  or  absorbed  by  the  leucocytes 
or  the  ferments  liberated  by  them  when  they  die.  Liquefaction  and  ab- 
sorption are  rarely  complete,  and  the  necrotic  tissue  is  only  separated 
from  the  healthy,  rarely  completely  liquefied  or  absorbed. 

3.  Regenerative  Changes. — The  first  signs  of  regeneration  ai-e  seen 
early  (after  twelve  hours).  The  protoplasm  of  the  connective  tissue 
cells  and  of  the  endothelial  cells  of  the  lymph  and  blood  vessels  increases 
in  amount,  and  numerous  mitotic  figures  may  be  seen,  indicating  that  the 
tissues  are  therefore  proliferating  actively.  It  is  difficult  to  determine  the 
origin  of  the  large,  round,  mononuclear  cells  which  stain  heavily  and 
characteristically  with  methylene  blue.  These  have  been  called  [ilasnui 
cells  by  TJnna,  who  regarded  them  as  derivatives  of  connective  tissue 
cells.  According  to  Marschalko,  Ribbert,  and  otliei-s,  tliey  are  derived 
from  large  lymphocytes. 

The  growth  of  tissue  increases  as  the  hyi>era'niia  an<l  exudiite  sul)side. 
resulting  in  the  developnu'ut  of  granulation  tissue,  which  is  composed 
of  fibroblasts,  leucocytes,  lymphocytes,  newly  formed  and  old  ground 
substance,  and  many  newly  formed  blood  vessels.    Eventually  the  granu- 


150       NATURE   OF   INFECTION;   LOCAL   AND   GENERAL   REACTION 

lation  tissue  fills  in  the  defects  resulting  from  the  uecrosis  and  lique- 
faction of  the  tissues.  Therefore  granulation  tissue  is  always  found  in 
ulcers  of  the  skin  and  mucous  membrane,  about  sequestra  in  bone,  in  the 
walls  of  abscesses  and  fistulae,  etc.  The  granulation  tissue  surround- 
ing dead  tissue  aids  in  separating  the  latter  (demarcation),  and  as  the 
inflammation  subsides,  produces  a  secretion  rich  in  leucocytes,  the  fer- 
ments of  which  digest  the  necrotic  tissue. 

The  granulation  tissue  becomes  transformed  into  scar  tissue  as  wound 
repair  progresses. 

Symptoms  of  Acute  Inflammation. — Th(>  classical  symptoms  of  acute 
inflammation,  which  were  described  by  Galen,  are  rubor  (redness),  tumor 
(swelling),  ealor  (heat),  and  dolor  (pain).  The  redness  and  the  local 
elevation  of  temperature  about  the  inflammatory  focus  are  due  to  the 
active  hypera?mia,  the  swelling  to  the  exudate,  the  pain  to  the  action 
of  bacterial  toxins,  and  the  other  harmful  agents  upon  the  nerve  end- 
ings. The  fifth  symptom,  which  is  sometimes  described  as  functio  Isesa, 
the  disturbed  function  of  the  part  of  the  body  involved,  is  due  to  the 
swelling  and  pain. 

Character  of  the  Inflammation  and  Clinical  Course. — The  character  of 
the  inflammation  is  determined  by  its  cause.  Sometimes  all  the  symp- 
toms are  pronounced,  sometimes  they  are  but  slightly  developed;  some- 
times hypersemia  and  exudation  predominate  (e.  g.,  inflammations  due 
to  pyogenic  bacteria)  ;  sometimes  degeneration  and  necrosis  (e.  g.,  cau- 
terization, burns,  and  frostbites  of  the  third  degree,  in  putrefactive  and 
severe  pyogenic  infections)  ;  and  sometimes  the  proliferation  of  tissues 
(e.  g.,  in  syphilis,  actinomycosis,  and  some  forms  of  tuberculosis). 

The  inflammations  associated  wdth  hyperjemia  and  exudation  have 
an  acute  clinical  course,  while  those  resulting  in  the  formation  of  large 
amounts  of  new  tissue  develop  gradually  and  are  chronic.  Intermediate 
forms  are  called  subacute.  The  clinical  course  depends  upon  the  viru- 
lence of  the  bacteria  and  the  resistance  of  the  tissues.  An  acute  inflam- 
mation may  become  chronic,  if  the  virulence  of  the  bacteria  diminishes; 
the  reverse  may  happen  if  the  virulence  increases.  The  character  of  the 
exudate  and  the  amount  of  local  tissue  degeneration  characterize  differ- 
ent forms  of  inflammation.     The  following  forms  may  be  distinguished : 

1.  In  serous  inflammation  a  watery  exudate  containing  large  amounts 
of  albumin  and  but  relatively  few  cells  is  formed.  It  gives  rise  in  mu- 
cous membranes  to  a  serous  discharge  mixed  with  mucus;  in  the  cutis  to 
the  formation  of  vesicles  with  clear  contents;  in  the  subcutaneous  tissue 
to  ;ni  iiidaiiiiiiiilory  O'dema ;  in  the  large  body  cavities,  joints,  and  bursa? 
to  chai-acteristic  serous  exudates.  Serous  inflammation  may  be  acute 
(erysipelas),  or  chronic  (tubei-culosis  of  serous  cavities),  depending  upon 
the  bacteria.     Serous  inflammations  may  be  associated  with  the  mildest 


LOCAL   REACTION  151 

(osteomyelitis  albuniinosa)  or  tlie  severest  infections  caused  by  pyofj^onic 
cocci  (seropurulent  phlegmon  j.  Frequently  there  are  transitions  to  the 
fibrinous  or  purulent  types,  the  fibrin  is  precipitated  or  the  serous  exu- 
date is  rich  in  cells. 

2.  Fibri)toi(s  inflammation  is  characterized  by  the  precipitation  of 
albuminous  bodies  dissolved  in  the  exudate.  Ferments  which  are  appar- 
ently derived  from  degenerating  cells,  especially  the  leucocytes,  are  re- 
quired for  the  precipitation  of  these  bodies.  The  fibrin  is  deposited  espe- 
cially upon  the  surfaces  of  mucous,  serous,  and  synovial  membranes, 
upon  ulcers  of  the  skin,  and  in  the  alveoli  of  the  lung,  rarely  in  the 
connective  tissues.  The  formation  of  fibrin  is  sometimes  combined  with 
necrosis  (coagulation  necrosis),  sometimes  with  serous  or  purulent  exu- 
dates. The  fibrin  forms  upon  the  mucous  membranes  a  gray  or  yel- 
lowish-white membrane — the  fibrinous  or  croupous  pseudo-membrane — 
which  occurs  in  diphtheria  and  other  inflannnations  of  mucous  mem- 
branes produced  by  the  staphylococcus,  streptococcus,  pneumococcus, 
and  typhoid  bacillus.  The  fibrin  layer  separates  easily,  where  only  the 
underlying  epithelium  is  destroyed,  and  for  this  reason  in  diphtheria  of 
the  bronchi  branched  fibrinous  masses,  casts  of  the  respiratory  passages, 
are  coughed  up.  When  the  fibrinous  threads  are  closely  attached  to  deep 
necrotic  tissue  of  the  mucous  membranes,  the  pseudo-membrane  becomes 
firmly  adherent  (pharyngeal  diphtheria). 

Upon  the  serous  membranes  of  the  body  cavities  and  the  s\  no  vial 
membranes  of  joints  and  bursa?  fibrinous  deposits  are  at  first  loose,  but 
become  organized  later  to  form  villous  or  nodular  growths  or  stratified 
callosities.  In  tuberculosis  of  joints  and  bursa;  these  fibrinous  deposits 
are  frequently  torn  loose  by  movements  and  rounded  off  to  f(n*m  ])odies 
which  resemble  seed  corn  (rice  bodies).  A  fibrinous  membrane  forms 
upon  granulating  ulcers  of  the  skin  in  wound  diphtheria,  and  is  asso- 
ciated with  purulent  secretion  in  many  dift'erent  kinds  of  infections.  Free 
flakes  of  fibrin  in  serous  or  seropurulent  exudates  are  usually  indicative 
of  tuberculous  inflammation. 

Microscopically  the  fibrinous  deposit  or  membrane  is  composed  of  an 
entangled  network  of  threads  of  fibrin  in  which  are  inclosed  epithelial 
and  connective  tissue  cells,  leucocytes,  and  groups  of  bacteria. 

3.  In  purulent  infiammations  a  yellowish,  creamy  exudate,  the  well- 
known  pus,  is  formed.  Pus  occurs  as  a  secretion  of  the  mucous  mem- 
brane mixed  with  mucus,  as  the  contents  of  pustules,  as  an  exudate  in  the 
tissues,  as  the  contents  of  tissue  spaces  following  liquefaction  of  dead 
tissues,  as  an  exudate  in  serous  cavities  and  joints  (empyema).  The 
characteristics  of  a  purulent  exudate  are  due  to  the  large  number  of 
cells,  especially  the  polynuclear  neutrophiles,  the  so-called  pus  corpuscles, 
which  it  contains. 


152        NATURE   OF    INFECTIOxM;   LOCAL   AND   GENERAL   REACTION 

The  loiijuer  the  pus  reniaiiis  in  the  body,  the  greater  tlie  amount  of  ne- 
crotic tissue  which  is  hekl  in  solution  by  the  ferments  liberated  by  the  de- 
generating leucocytes  it  contains  (Fredr.  Mueller).  Old  pus  contains 
fresh  and  old  leucocytes,  proliferated  connective  tissue  cells,  lympho- 
cytes, red  blood  corpuscles,  epithelial  cells,  all  of  which  are  more  or  less 
degenerated,  also  pieces  and  shreds  of  separated  and  fibrillated  connec- 
tive tissue,  bone-sand,  etc. 

The  pyogenic  bacteria  are  the  chief  causes  of  suppuration.  It  can 
be  produced  experimentally  by  the  injections  of  chemical  agents  (tur- 
pentine, mercury,  petroleum,  etc.),  but  such  inflammation  is  never  pro- 
gressive, always  remaining  localized. 

It  is  difficult  to  determine  why  fibrin  is  frequently  not  found  in  pus ; 
possibly  the  bacterial  toxins  prevent  its  precipitation.  A  fibrinopuru- 
lent  exudate  is  frequently  seen  in  tuberculosis,  also  in  purulent  inflam- 
mations of  the  serous  cavities  and  joints.  A  thin  yellowish,  cloudy  exu- 
date, rich  in  cells,  is  called  a  seropurulent  exudate.  The  character  of  the 
pus  differs  in  different  infections.  Stajihylococcic  pus  is  creamy  and 
yellowish;  streptococcic  and  pneumococcic  pus  is  thinner  and  yellowish 
green ;  the  pus  produced  by  the  bacillus  pyocyaneus  colors  the  skin  and 
bandages  bluish  green ;  tuberculous  pus  is  thin  and  flocculent ;  typhoid 
pus  is  brownish,  thin,  and  contains  pieces  of  necrotic  tissue. 

4.  Serofihrinous  and  purulent  exudates  which  contain  considerable 
quantities  of  blood  are  called  hemorrhagic  exudates  (tuberculous  pleu- 
ritis,  pericarditis,  general  hamiorrhagic  infection,  severe  inflannnations 
of  mucous  membranes). 

5.  In  the  icliorous  or  putrefactive  inflammation,  due  to  putrefactive 
bacteria,  destruction  of  the  tissues  and  putrefaction  (gangrene)  pre- 
dominate. The  exudate  in  the  beginning  is  serous  and  contains  few  cells, 
later  it  is  bloody  and  mixed  with  detritus  and  gas  bubbles,  and  there- 
fore becomes  discolored  and  stinking   (foul-sanies). 

Results  of  Inflammation. — In  any  of  these  forms  of  inflammation  the 
necrosis  of  the  tissues  may  be  very  extensive.  Necrosis  is  extensive,  for 
exami)Ie,  in  local  anthrax  infections,  in  severe  streptococcic  phlegmons 
Math  a  serous  or  seropurulent  exudate,  in  inflamitiations  of  the  mucous 
membranes  due  to  the  dij^htherla  or  typhoid  bacillus  or  pyogenic  cocci 
with  fibrinous  exudate,  in  suppurative  phlegmons  and  osteomyelitis  due 
to  pyogenic  bacteria. 

An  inflammation  may  pursue  an  acute  or  chronic  course.  As  a  rule, 
the  difference  in  clinical  picture  depends  upon  the  cause  of  the  inflam- 
mation. A  concentrated  caustic  produces  a  more  violent  inflammation 
than  one  that  is  diluted,  but  the  latter,  if  ai)plied  fre(|uently,  maintains  a 
certain  degi-ee  of  iiiHaimiiation  for  some  time.  The  same  is  true  of 
bacterial    indammatious,  wJiich  may  be  rightly  compared  to  the  chemi- 


LOCAL   REACT  I  (JN  153 

cal  inflammations,  because  the  toxins  play  such  an  important  role.  For- 
eign bodies  and  necrotic  tissue — for  example,  a  sequestrum  followinjr 
a  suppurative  osteomyelitis — irritate  continually  the  surrounding,'  tissues, 
and  for  this  reason  a  chronic  inflammation  persists.  While  acute  in- 
flammation is  associated  with  hypera^mia,  exudation,  and  often  with 
extensive  necrosis,  these  processes  are  not  marked  in  chronic  inflamma- 
tions, which  develop  slowly,  and  often  not  to  any  j^reat  extent.  The  pro- 
liferative processes  are  most  pronounced  in  the  chronic  inflammations, 
and  as  a  result  of  the  proliferation  of  the  fibrous  tissues,  periosteum, 
bone,  and  adenoid  tissue,  growths  slowly  develop  which  may  attain  con- 
siderable size  (e.  g.,  elephantiasis  of  the  skin,  callosities,  connective  tis- 
sue thickenings  of  serous  membranes,  hyperostoses,  chronic  tonsillar  and 
lymphadenoid  hyperplasia) . 

In  a  number  of  bacterial  infections  the  proliferation  of  ccmnective 
tissue  about  the  inflammatory  focus  is  so  great  that  nodular  granulation 
growths,  the  so-called  granulation  tumors  or  granulomas  develop,  as,  for 
example,  in  tuberculosis,  syphilis,  leprosy,  chronic  glanders,  actinomy- 
cosis, and  rhinoscleroma.  These  granulation  growths  contain  the  specific 
cause  of  the  infiammation,  which  invades  the  normal  tissue  and  gives  to 
the  disease  in  question  its  characteristic  features.  If  in  these  chronic  in- 
flammations an  exudate  is  formed  (e.  g.,  in  tuberculosis,  seropurulent 
or  serofibrinous  effusions  in  joints  and  body  cavities,  hydrops  of  the  joint 
in  syphilis)  they  pursue  a  chronic  course,  and  there  are  only  slight 
symptoms  of  inflammation. 

Chronic  interstitial  inflammation  of  muscles  and  viscera  is  followed 
by  an  atrophy  of  the  parenchyma  due  to  the  contraction  of  the  newly 
formed  connective  tissues  (muscle  scar,  contracted  kidney,  cirrhosis  of 
the  liver). 

Literature. — Buchner.  Natvirliche  Sehutzeinrichtungcii  dcs  Organisnuis  unci 
deren  Beeinflussung  zum  Zweck  der  Al^wehr  von  Infektionsprozessen.  Miinch.  ined. 
Wochenschr.,  1899,  Nos.  39  and  40. — Cohnheim.  Vorlcsiuigen  vibcr  allgcni.  Pathologic. 
Leipzig,  1882. — Graser.  Die  erste  Verklebung  der  serosen  Hiiiite.  Chirurg.-Kongr. 
Verhandl.,  1895,  II,  p.  625. — Hcidenhain.  Zur  Lelire  von  ilcr  Lyniphbildung.  .Vrciiiv 
f.  d.  gesammte  Physiologic,  Bd.  49,  1891,  p.  209. — Herxheimer.  Fibrinose  iMitziindimgcn. 
Virchows  Archiv,  Bd.  162,  1900,  p.  443. — Luivderer.  Zur  Lehre  von  der  I'hitziintlung. 
V.  Volkmanns  Samml.  klin.  Vortrage,  1885,  No.  259. — Leber.  Die  Entstehung  d. 
Entzi'indung.  Leipzig,  1891. — Lubarsch.  Entzi'indung.  Ergebnisse  der  allgeni.  Path. 
V.  Lubarsch  u.  Ostertag,  3.  Jahrg.,  1896,  p.  61 1. — Muscatello.  Zur  Frage  der  Entziinduiig 
u.  Verwachsung  seroser  Flaute.  Miinch.  ined.  Wochenschr.,  1900,  p.  688. — Friedr. 
Mailer.  Ueber  d.  Bedeutung  d.  Selbstverdauiuig  bci  cinigen  krankhaften  Zu-stiindcn. 
20.  Kongress  d.  inn.  Med.,  1902. — Pappenhelm.  Zur  Plasniazcllcnfragc.  Virchow.s 
Arch.,  Bd.  169,  1902,  p.  372.— v.  Recklinglutiiseii.  Allgcin.  Path.  d.  Krci.slaufs  u.  d. 
Erniihrung,  Stuttgart,  imii.—Rihbert.  Lehrbuch  d.  allgcni.  Path.  Lcii)zig,  1905;  - 
Die  Betlcutung  der  Entztnidung.  Bonn.  1905.— /?/7/rr.  Die  Entstehung  dor  ent- 
ziuidUchen  HyiJeraniie.     Miltcil.  a.  d.  (.ircnzgcl)ictcn.  Bd.   12.  1903,  and  Bd.  15,  1905. 


154       NATURE    OF    INFECTION;    LOCAL   AND   GENERAL   REACTION 

— Schlesinger.  L^eber  Plasmazellen  unci  Lymphozyten.  Virchows  Arch.,  Bd.  169,  1902, 
p.  428. — Virchow.  Die  Rolle  der  Gefasse  und  des  Parenchyms  in  der  Entziinduiig. 
Virchows  Arch.,  Bd.  149,  1897,  p.  381. — Zicgler.  Entziindung.  Eulenburgs  Realen- 
zyklopildie,  Bd.  7,  1895. 


CHAPTER    III 

THE    GENERAL    REACTION 

The  general  reaction  following  a  local  infection  begins  with  the 
diffusion  of  the  bacteria  and  their  toxins  in  the  body,  the  first  symptoms 
being  usually  the  direct  result  of  absorption.  Bacteria  pass  so  rapidly 
from  a  recent  infected  wound  into  the  blood,  and  from  this  into  the 
viscera  that  their  direct  entrance  into  the  injured  capillaries  must  be 
considered  as  probable.  The  absorption  by  the  lymphatics,  and  the 
deposition  of  bacteria  in  the  lymph  nodes,  also  play  a  great  role.  Patho- 
genic are  absorbed  as  rapidly  as  the  saprophytic  bacteria  (Schimmel- 
busch,  Noetzel). 

Rapidity  of  Absorption  from  Different  Kinds  of  Wounds. — Only  fresh 
wounds,  the  incised  more  than  contused  or  lacerated  wounds,  have  this 
property  of  inniiediate  absorption.  An  old  wound,  over  which  the  plasma 
has  formed  a  protective  covering,  gangrenous  and  uninjured  granulating 
wounds  do  not  absorb.  A  rapid  absorption  of  bacteria  and  their  toxins 
occurs  when  uninjured  nuicoiis  membranes  are  invaded  by  highly  viru- 
lent bacteria  (Lexer,  Bail,  vide  Infection  Atria  of  Pyogenic  Infections). 
The  different  tissues  of  the  body  behave  very  differently  as  regards  the 
absorption  of  bacteria  from  recent  infected  wounds  (e.  g.,  infection  of 
operation-wound).  The  peritoneum  absorbs  most  rapidly,  and  therefore 
is  more  resistant  to  mild  infections  than  the  subcutaneous  tissues  or  syno- 
vial membranes,  while  general  infections  follow  rapidly  virulent  infec- 
tions of  the  peritoneum.  In  the  later  course  of  any  infection  the  inva- 
sion of  the  lymphatic  vessels  and  blood  vessels  by  bacteria  plays  an 
important  part  in  the  dift'usion  of  bacteria  and  their  toxins  and  the 
development  of  a  general  infection. 

Experiinents.have  demonstrated  that  absor])tion  from  fresh  wounds 
begins  before  the  local  reaction,  and  that  it  continues  until  the  inflam- 
matory focus  is  encapsulated,  until  the  bacteria  are  removed  or  escape 
is  provided  for  them  by  operative  procedures,  or  they  are  deposited  in  the 
lymph  glands,  blood  and  organs,  where  they  come  in  contact  with  and  are 
destroyed  by  the  bactericidal  substances,  (ieneral  infection  is  prevented 
in  mild  infections  or  infections  of  average  sevei'ity  (mly,  and  in  these 
cases  the  local  reaction  protects  the  infection  atria.     According  to  the 


THE   GENERAL    REACTION  155 

later  invest i<i:at ion  it  is  doubtful  whether  there  is  a  physiolofrical  secretion 
of  bacteria  by  the  kidneys,  without  any  disease  of  the  same,  and  by 
the  sweat  glands  {vide  Leuhartz,  Wrede). 

Relation  of  Clinical  Symptoms  to  Virulence  of  Bacteria  and  Lowered 
Resistance  of  Organism. — Jt  depends  upon  tlu'  viruU'nee  of  the  bacteria 
whether  the  clinical  symptoms  of  general  infection  begin  early  or  late, 
or  whether  they  develop  at  all.  While  the  absorption  of  highly  virulent 
bacteria  such  as,  for  example,  those  derived  from  an  inflammatory  process 
in  another  patient,  give  rise  to  immediate  symptoms,  those  coming  from 
the  outer  world  must  become  adapted  to  the  tissues,  hold  their  own 
against  the  bactericidal  properties  of  the  latter  and  develop,  before  their 
absorption  and  entrance  into  blood  vessels  give  rise  to  general  symptoms. 
The  bacteria  are  not  able  to  develop  in  many  cases  when  introduced 
into  wounds,  and  when  they  do  a  period  of  incubation  is  necessary  {vide 
p.  146). 

If  the  absorbed  bacteria  are  too  virulent  or  are  present  in  too  large 
numbers,  or  the  organism  is  weakened  and  its  resistance  therefore  re- 
duced, they  will  not  be  destroyed,  and  as  a  result  they  will  either  be 
deposited  in  the  tissues  (bacterial  metastasis)  or  develop  in  the  blood 
and  flood  the  organism  (blood  infection).  While  all  these  processes 
may  occur  with  one  form  of  bacteria — e.  g.,  pyogenic  cocci — the  process 
may  be  entirely  different  with  another  form.  For  example,  in  glanders 
metastasic  foci  are  the  rule;  in  anthrax  there  is  a  general  blood  infec- 
tion ;  in  tetanus  and  diphtheria  bacteria  are  but  rarely  found  in  the 
blood  and  tissues,  the  infection  being  toxic,  while  in  miliary  tubercu- 
losis, which  may  follow  directly  the  rupture  of  a  tuberculous  focus  into 
a  large  vessel  (e.  g.,  a  branch  of  the  pulmonary  vein),  great  numbers 
of  metastatic  foci  develop  in  the  different  viscera  and  tissues. 

The  most  virulent  general  bacterial  infections  characterized  by  devel- 
opment of  bacteria  in  the  blood  occur  only  when  all  the  natural  pro- 
tective powers  of  the  body  are  greatly  reduced  or  exhausted. 

Bactericidal  Substances  in  Tissue  Fluids. — The  bactericidal  sub- 
stances which  give  to  the  organism  natural  protective  powers  are  nor- 
mally present  in  the  lymph,  blood,  and  tissue  fluids.  They  are  produced 
by  the  activity  of  certain  cells,  especially  the  leucocytes.  The  greater 
part  of  the  natural  resistance  depends  upon  these  bodies.  Blood  serum 
taken  from  a  healthy  body  has  the  property  of  dissolving  or  aggluti- 
nating a  number  of  ditt'erent  varieties  of  bacteria,  and  the  blood  cor- 
puscles of  another  species.  The  substances  which  do  this  are  called  from 
their  action  baeteriolysins,  ha'iiiolysins,  bacterioagglutinins,  ha?maggluti- 
nins,  and,  according  to  Behring,  this  action  is  due  to  a  single  albuminous- 
like  body  which  is  contained  in  the  serum,  the  alexin  (from  dXc^eiv, 
meaning  to  protect).     The  alexin  is  so  unstable  that  it  is  rapidly  de- 


156       NATURE   OF   INFECTION;   LOCAL   AND   GENERAL   REACTION 

stroyed  after  being  taken  from  the  body,  and  becomes  inert  immediately 
when  heated  to  55°  C.  According  to  Ehrlich  and  Morgenroth  this  bac- 
tericidal and  agglutinating  property  of  serum  does  not  depend  upon 
a  single  substance,  the  alexin,  but  upon  the  combined  action  of  different 
bodies.  Experiments  have  demonstrated  that  the  action  of  the  serum 
depends  upon  two  bodies,  one  of  which,  tlie  complement  (corresponding 
to  the  alexin),  is  thermolabile  and  quickly  destroyed  when  the  serum 
is  heated  to  55°  C. ;  while  the  other,  the  intermediary  body  which  forms 
the  bond  of  union  between  the  bacteria  or  red  blood  corpuscles  of  an- 
other species  and  makes  possible  the  digestive  or  fermentlike  action  of 
the  complement,  resists  heating. 

These  two  bodies  are  multiple,  and  different  intermediary  bodies  and 
complements  are  present  in  the  serum  vrhich  are  specific  for  different 
bacteria  and  cells,  and  even  for  different  species  (typhoid,  cholera  bacilli, 
and  blood  corpuscles  of  dift'erent  species).  For  this  reason  a  serum 
which  has  agglutinated  typhoid  bacilli  can  still  agglutinate  cholera  ba- 
cilli, but  is  no  longer  able  to  act  upon  typhoid  bacilli. 

A  serum  the  complement  of  which  has  been  destroyed  by  heat  is 
inactive.  It,  however,  may  still  contain  the  intermediary  body,  and  be- 
comes active  again  as  soon  as  normal  serum  containing  the  complement 
is  added  to  it.     The  inactive  serum  is  then  reactivated. 

Normally  there  are  only  small  amounts  of  the  intermediary  bodies 
in  the  serum.  They  are,  however,  formed  during  an  infection,  and  when 
the  infection  subsides  are  present  in  large  amounts  within  a  short  time. 
This  increase  does  not  affect  all  the  intermediary  bodies,  however,  but 
only  those  which  are  active  against  the  bacteria  producing  the  infection. 
These  are  then  called  immune  bodies,  for  they  give  to  the  sermn  its  most 
important  bactericidal  and  agglutinating  properties.  If  an  animal  has 
been  immunized  against  typhoid,  its  serum  will  dissolve  typhoid  bacilli, 
but  only  these,  as  the  immune  body  is  specific  for  the  typhoid  bacillus. 
In  the  immunization  the  complement  is  not  increased.  (Concerning  the 
production  of  the  immune  body,  see  Ehrlich 's  theory.) 

The  action  of  the  normally  present  or  newly  formed  protective  sub- 
stances is  successful  only  when  the  bacteria  are  not  too  virulent  and  do 
not  multiply  too  rapidly.  In  virulent  infections  with  rapid  course  the 
bactericidal  bodies  do  not  suffice,  and  are  not  formed  in  large  enough 
quantities. 

Decrease  of  Protective  Substances. — The  decrease  of  the  protective 
bodies,  especially  of  the  complement,  predisposes  to  infection — e.  g.,  if 
the  complement  has  been  exhausted  by  infection  or  sufficient  quantities 
are  not  produced  because  of  disease  of  the  internal  organs  (Ehrlieh 
and  Morgenroth).  Von  Dnngern  luis  made  the  very  significant  ob- 
servation that  the  complement  becomes  united  with  dead  tissue,   and 


THE  GENERAL  REACTION  157 

explains  in  this  way  tlie  increased  local  predisposition  to  infection  after 
injury. 

Local  Increase  in  Protective  Substances  Artificially  Induced. — A  local 
increase  of  these  protective  bodies  may  l)e  produced  artificially.  The 
organism  responds  to  any  irritation  by  hyporaMuia,  and  then  increased 
amounts  of  the  bactericidal  bodies  of  the  blood  are  carried  to  the  injured 
area,  and  when  the  blood  stream  slows  {vide  Inflammation)  these  pass 
out  into  the  tissues.  A  local  accumulation  of  intermediary  bodies  and 
complement  may  be  produced  by  inducing  an  artificial  hyperemia  or 
increasing  a  preexistent  hyperasmia  (Wassermann).  The  favorable  in- 
fluence which  those  agents  producing  a  mild  hyperaMuia  (tincture  of 
iodine,  alcohol,  compresses  and  poultices)  exercise  upon  mild  and  chronic 
inflammation,  depends  mostly  upon  this  increase  in  intermediary  bodies 
and  complement.  These  same  agents  do  harm  in  acute  inflammations, 
as  the  hyperamiia,  and  consequently  the  exudate,  is  increased,  and  the 
formation  of  pus  and  the  digestion  of  the  tissues  is  hastened  or  grave 
circulatory  disturbances  followed  by  extensive  necrosis  are  induced. 

A  large  accumulation  of  bactericidal  substances  accompanies  the 
passive  (venous)  hyperaemia,  which  is  recommended  by  Bier  as  a  thera- 
peutic measure  in  the  treatment  of  infections,  especially  for  tuberculosis 
of  the  extremities,  gonorrheal  arthritis,  and  acute  inflammations  of  all 
kinds.  Its  use,  however,  may  be  compared  to  that  of  a  two-edged  sword, 
for  the  good  which  follows  the  exudation  of  blood  plasma  and  the  emi- 
gration of  leucocytes  may  be  counterbalanced  by  the  nutritional  disturb- 
ances which  follow  too  long  and  severe  compression  and  the  slower 
absorption  of  toxins  from  the  inflammatory  focus  which  injure  the 
tissues.  Clinical  experience,  and  the  animal  experiments  performed  by 
Notzel,  have  demonstrated  that  passive  hyperaemia  may  under  certain 
conditions  prove  injurious.  Even  if  properly  controlled,  passive  hy- 
peraemia may  do  harm,  for  after  the  constrictor  is  removed  there  is  an 
increased  absorption  of  the  pyogenic  endotoxins  which  have  been  lib- 
erated by  bacteriolysis  and  an  increase  of  proteolytic  ferments,  which 
are  derived  from  the  leucocytes.  Passive  hypera^nia  is  especially  in- 
jurious in  virulent  and  acute  infections  which  have  lasted  some  time 
(Lexer). 

A  vigorous,  active  hyperaemia  such  as  that  produced  by  Bier's  hot-air 
apparatus  hastens  absorption,  and  for  this  reason  acts  favorably  in  many 
cases  of  chronic  articular  rheumatism,  chronic  o'dema,  etc.   (Bier). 

The  Source  of  Bactericidal  Suhstances.—The  source  of  the  bacteri- 
cidal substances  found  in  the  blood  serum  has  not  been  accurately  de- 
termined. According  to  Buehner  and  IMetschnikoff,  the  complement  or 
alexin  is  derived  from  the  leucocytes;  Buehner  regarding  it  as  a  secre- 
tion, Metschnikoff  as  a  degeneration  product.    A  number  of  experiments. 


158       NATURE   OF   INFECTION;   LOCAL   AND   GENERAL   REACTION 

such  as  tlioso  of  A.  AVasserinaiin,  who  has  iii'ochiecd  an  anticoiiipk^nient 
by  imniuiiizing  animals  with  leucocytes,  and  moreover  the  increase  in 
the  bactericidal  properties  of  an  exudate  by  artificially  increasing  the 
number  of  leucocytes,  indicate  that  the  latter  is  one,  l)ut  not  the  only 
source  of  the  complement  (A.  Wassermann).  The  experiments  of  Ehr- 
lich  and  IMorgein'oth  have  shown  that  other  cells — e.  g.,  liver  cells — may 
produce  complement,  for  if  the  liver  is  artificially  excluded  from  the 
circulation  the  amount  of  complement  is  reduced. 

Bdation  hctwceii  Leucocytes  anel  Complemoit. — The  relation  between 
the  leucocytes  and  the  complement  explains  the  value  of  two  phenomena 
occurring  in  infections,  the  accumulation  of  leucocytes  at  the  point  of 
invasion  {vide  Infiammation)  and  the  increase  of  leucocytes  in  the  blood 
(active  leucoeytosis),  w^hich  occurs  in  almost  all  febrile  infectious  dis- 
eases (with  the  exception  of  typhoid,  measles,  and  malaria),  and  also 
when  infectious  substances  from  suppurative  or  putrefactive  foci  are  ab- 
sorbed. These  phenomena  may  be  produced  experimentally  if  irritating 
substances  which  attract  the  motile  leucocytes  are  injected  into  some  part 
of  the  body  or  into  the  blood.  This  process  of  positive  ehemotaxis  (or 
chemotropism )  may  be  induced  by  a  number  of  chemical  agents  and 
bacterial  poisons,  particularly  by  the  bacterial  proteins,  albuminous  sub- 
stances produced  in  the  degeneration  of  the  bacterial  protoplasm  (Buch- 
ner,  Romer).  These  poisonous  substances  derived  from  bacteria  attract 
the  leucocytes  and  produce  a  local  accumulation  in  the  inflammatory 
focus,  and  after  their  absorption  an  increase  in  the  blood  of  those  cells 
which  give  rise  to  the  bactericidal  substances.  The  absence  of  leuco- 
eytosis in  suppurative  processes  or  general  infections  indicates  either 
that  the  organism  can  successfully  combat  without  effort  the  bacteria 
and  their  toxins  or  that  the  organism  is  too  weak  to  continue  the  strug- 
gle. The  same  relations  hold  true  at  the  point  of  infection  {vkle  Pyo- 
genic Infections). 

Leucoeytosis. — In  leucoeytosis  there  is  an  increase  of  white  corpuscles 
to  over  10,000  in  1  e.mm.  of  blood,  without  a  decrease  in  the  number  of 
red  corpuscles.  That  variety  of  leucocyte  which  is  normally  present  in 
greatest  numbers  (sixty-five  to  seventy  per  cent)  and  which  in  inflam- 
mation emigrates  in  greatest  number  from  the  blood  vessels,  the  poly- 
morphonuclear neutrophile  leucocytes,  is  increased.  They  differ  from 
the  other  leucocytes  in  that  their  protoplasm  stains  only  with  the  neu- 
tral, not  with  the  acid  or  basic  dyes;  their  luicleus  is  irr(>gularly  lobu- 
lated,  of  horseshoe  or  clover  leaf  shape,  and  stains  deeply  with  basic 
dyes.  According  to  Ehrlich,  they  are  formed  mostly  in  the  bone  marrow, 
but  also  to  some  extent  in  the  lymphatic  system  (E.  Grawitz). 

Diofpiostic  Siffvificance  of  Leucoeytosis. — Ijeucocytosis  has  l)een  used 
for  diagnostic.  ])U)'|)(ises  (Curschmann)  to  recognize  deep-seated  suppura- 


THE   GENERAL   REACTION  159 

tion,  particularly  suppuration  associated  with  appendicitis.  But  a  mod- 
erate leucocytosis  may  accompany  the  formation  of  any  inflanuiiatory 
exudate  (e.  g.,  pneumonia),  and  may  be  absent  in  large  intraperitoneal 
abscesses,  apparently  because  encapsulated.  Leucocytosis  is  therefore 
of  nnich  less  diagnostic  significance  than  the  clinical  symptoms.  [Leu- 
cocytosis is  of  value  in  diagnosis  when  it  is  considered  with  the  clinical 
symptoms.  J 

Leucocytes  are  also  able  by  their  am(e])oid  movements  to  surroiuid 
organic  particles  (dust,  pigment,  detritus,  bacteria)  and  to  ingest  them. 
According  to  Metschnikoff's  idea  of  phagocytosis,  the  leucocytes  wage 
active  warfare  against  the  bacteria,  ingest  living  bacteria  and  destroy 
them.  Leucocytes  are  therefore  called  eating  cells  or  phagocytes.  Ac- 
cording to  Weigert,  Buchner  and  others,  virulent  bacteria  are  not  in- 
gested by  leucocytes,  but  only  those  which  have  been  previously  injured 
or  killed  by  the  bactericidal  substances  in  the  blood  serum.  Certain 
micro-organisms  (gonococci,  leprosy  and  tubercle  bacilli),  however,  mul- 
tiply within  the  leucocytes,  and  must,  therefore,  have  been  viable  when 
ingested. 

Infected  tissues  absorb  not  only  bacteria,  but  their  poisons  (toxins 
and  endotoxins)  as  well. 

Ehrlich's  Side-chain  Theory,  Action  of  Immune  Sera,  etc. — It  is  only 
possible  to  demonstrate  experimental^^  the  presence  of  toxins  in  the 
blood  shortly  before  or  after  death,  and  when  they  are  produced  in  large 
quantities,  as  in  tetanus  and  diphtheria.  As  a  rule,  the  absorbed  toxins 
do  not  remain  in  the  blood  unless  produced  in  large  amounts  in  severe 
cases  of  the  diseases  above  mentioned.  The  toxins  have  a  specific  rela- 
tion to  certain  cells  by  which  they  are  attracted  and  bound,  and  upon 
which  they  act.  Tetanus  toxin,  for  example,  which  experimentally  is 
bound  by  the  substance  of  the  central  nervous  system  of  susceptible 
animals,  is  drawn  from  the  blood  by  the  nerve  cells  and  acts  upon  them. 
In  unsusceptible  animals  the  toxins  circulate  in  the  blood,  producing 
no  symptoms,  as  they  are  not  attracted  and  bound  by  the  cells. 

The  union  of  the  toxin  with  the  cell  is  explained  by  Ehrlich  in  the 
following  way:  The  toxin  molecule  possesses  a  haptophore  and  a  toxo- 
phore  group.  By  means  of  the  former  the  toxin  becomes  attached  to 
the  cell,  and  then  the  toxic  properties  residing  in  the  latter  become 
active.  In  Ehrlich's  theory  the  activities  of  the  living  cell  reside  in  a 
"  Leistung-kern  "  (action  center  or  nucleus)  and  in  different  "  Seiten- 
functionen  "  or  side-chains  (receptors),  which  bind  and  assimilate  the 
food  substances.  The  toxin  is  bound  as  follows:  Its  haptophore  group 
becomes  attached  to  definite  side-chains  or  receptors  of  certain  cells,  into 
which  the  haptophore  group  of  the  toxin  fits  like  a  key  in  a  keyhole, 
using  the  comparison  made  by  E.  Fischer.     The  susceptible  cells  which 


160      iNATURE   OF   INFECTION;   LOCAL   AND   GENERAL   REACTION 

bind  the  tetanus  toxin,  for  example,  are  found  in  the  central  nervous 
system,  and  the  toxin  becomes  united  with  these  cells  and  acts  upon  them. 
The  location  of  the  cell  groups  which  bind  the  toxins  in  other  infections 
is  unknown  as  yet. 

Ehrlich's  side-chain  theory  also  explains  the  complicated  processes 
which  provide  for  the  production  of  antitoxins  and  the  immunization  of 
the  individual. 

If  an  animal  has  been  rendered  immune  against  tetanus  by  the  ad- 
ministration of  gradually  increasing  doses  of  tetanus  toxin,  so  that  the 
fatal  dose  of  the  toxin  can  be  borne  without  harm,  the  blood  serum  of 
the  immunized  animal  will  protect  another  animal  from  the  ordinarily 
fatal  action  of  tetanus  toxins  or  infections.  The  serum  now  contains 
an  antitoxin  for  tetanus  which  binds  the  toxin  and  renders  it  harmless. 
This  was  first  demonstrated  for  tetanus  in  1890  by  Behring  and  Kitasato, 
and  has  become  generally  known  in  experimental  work  as  "  Behring 's 
law."  The  blood  serum  of  an  individual  rendered  immune  spontane- 
ously (by  disease)  or  artificiall}^  (by  inoculation  with  living  cultures  or 
with  toxins)  against  a  certain  disease,  when  injected  transfers  the  im- 
munity against  the  disease  in  question  to  a  susceptible  individual.  Ac- 
tive immunization,  produced  by  the  injection  of  increasing  doses  of  toxic 
substances  against  which  antibodies  are  formed,  is  differentiated  from 
passive  immunization,  which  is  produced  by  the  injection  of  the  blood 
serum  of  an  animal  alread}^  immunized.  Active  immunization  resem- 
bles acquired  immunity,  which  occurs  w'hen  a  patient  recovers  from  a 
disease.  As  in  tetanus,  so  in  diphtheria,  immunity  depends  upon  the 
production  of  antibodies,  which  act  upon  the  toxins.  In  other  infec- 
tions the  antibodies  do  not  act  upon  the  toxins,  but  upon  the  bacteria 
themselves.  Animals  may  be  immunized  against  poisons  other  than  those 
produced  by  bacteria.  They  may  be  immunized  against  toxic  albuminous- 
like  substances  derived  from  plants,  such  as  ricin  and  abrin  (Ehrlich), 
against  snake  venom  (Calmette),  not,  however,  against  other  toxic  sub- 
stances (alkaloids). 

According  to  the  side-chain  theory,  in  the  innnunizing  process  (as 
in  natural  infections)  the  toxins  which  are  injected  become  united  with 
the  susceptible  cells,  in  tetanus,  for  example,  with  the  cells  of  the  central 
nervous  system,  for  the  side-chains  or  receptors  of  the  cells  become  firmly 
attached  to  the  haptophore  group  of  the  toxin.  The  toxin  does  not  pro- 
duce fatal  results,  for  in  the  beginning  of  artificial  immunity  only  small 
attenuated  nonlethal  doses,  which  are  gradually  increased,  are  injected. 
'^I'he  sidi^-chains  or  i-eceptors  which  are  bound  by  toxin  no  longer  func- 
tionate, ;iii(l  arc  no  loiigcr  ol'  any  use  t<»  tlie  cell.  According  to  Ehrlich, 
when  tlic  side-chains  aic  hound  new  sicU'-chains  are  formed,  not  simply 
to  replace  those  already  destroyed,  but  in  excess,  this  explanation  being 


THE  GENERAL  REACTION  161 

based  upon  the  hypothesis  advanced  by  Weigert  that  in  regeneration 
after  injury  tissues  tend  to  reproduce  not  only  to  the  extent  of  repairing 
the  injury,  but  in  excess.  Only  those  side-chains  whieh  are  required  to 
replace  those  destroyed  remain  attached  to  the  cell,  the  remainder  are 
thrown  off  into  the  blood.  The  blood,  as  well  as  the  susceptible  cells,  now 
contains  side-chains  or  receptors  which  are  able  to  bind  the  toxin.  AVhile 
the  side-chains  attached  to  the  cells  render  possible  the  action  of  the  tox- 
ins upon  the  cell,  the  free  side-chains  circulating  in  the  blood  render  the 
toxins  harndess  as  they  become  united  witli  the  latter,  which  can  then 
no  longer  reach  the  susceptible  cells  and  destroy  them.  The  excessive 
side-chains  or  receptors  which  are  cast  off  into  the  blood  therefore  form 
the  antitoxin  and  the  nucleus  of  every  innnune  serum. 

Antitoxic  Serum. — Antitoxic  serum  (e.  g.,  in  tetanus,  diphtheria)  neu- 
tralizes only  the  toxin.  The  bacteria  remain  viable,  and  are  gradually 
destroyed  by  the  bacteriolytic  powers  of  the  organism,  perhaps  also  by 
the  saprophytes. 

Besides  the  infections  mentioned  above  in  which  the  antibodies  ob- 
tained by  immunization  are  antitoxic,  there  is  a  second  group  of  infec- 
tious diseases  in  which  the  blood  serum  of  a  patient  who  has  recovered 
from  the  disease  or  of  an  animal  which  has  been  innnunized  contains 
specific  bactericidal  antibodies,  which  act  upon  the  bacteria  themselves 
without  neutralizing  their  toxins  (cholera,  typhoid,  plague).  There  is 
the  following  difference  between  these  two  antibodies  when  the  treat- 
ment of  infections  is  considered :  Antitoxic  sera  may  be  expected  to 
cure  the  disease,  while  bactericidal  sera  have  only  an  immunizing  action, 
and  for  that  reason  are  only  of  value  in  prophylaxis.  Bactericidal  sera 
may  even  do  harm  if  the  disease  has  already  developed,  for  large  amounts 
of  endotoxins  are  set  free  suddenly  by  the  bacteriolysis  which  they  induce. 

Bactericidal  Serum. — The  bactericidal  immune  serum  (e.  g.,  in  ty- 
phoid, cholera  infection)  contains  a  speeilic  innnune  body.  This  is  the 
specific  intermediary  body  already  present  in  the  serum,  but  which  has 
been  increased  by  innnunization  {vide  p.  15G).  The  immune  body  be- 
comes attached  on  one  side  to  tlie  bacteria,  and  on  the  other  to  the  com- 
plement already  present  in  the  normal  serum,  and  renders  j^ossible  the 
digestive  action  of  the  latter  upon  the  bacteria.  xV  small  amount  of  such 
immune  serum  injected  into  a  normal  animal  suffices  to  protect  it,  for 
the  bacteria  which  ordinarily  would  produce  fatal  results  are  dissolved 
in  the  tissues.  Innnune  sera  taken  from  the  body  lose  their  power  after 
a  few  days,  for  the  labile  complement  is  rapidly  destroyed  outside  the 
body.  As  soon,  however,  as  fresh  serum  from  a  normal  animal  is  added, 
the  power  returns.  New  complement  has  been  added  and  the  innnune 
body  is  still  in  the  serum  (Metschnikoft*). 

The  production  of  the  specific  innnune  body  is  explained  by  Ehrlich's 


162       NATURE   OF   INFECTION:   LOCAL   AND   GENERAL   REACTION 

theory  in  the  same  way  as  the  production  of  antitoxin.  The  toxie  sub- 
stances produced  i)artiy  l)y  bacterial  metabolism  and  partly  by  bacteri- 
olysis find  in  the  cells  specific  side-chains.  Tlie  bound  side-chains  are 
replaced  in  excess,  and  the  excessive  side-chains  are  thrown  olif  into  the 
blood.  These  side-chains,  Avhich  are  the  immune  bodies,  become  bound 
to  the  bacteria  and  render  possible  the  digestive  action  of  the  complement. 
The  source  of  the  immune  body  for  all  infections  is  not  known.  Accord- 
ing to  Pfeift'er,  Marx,  and  A.  AVassermann,  the  medulla  of  bone,  the 
spleen,  and  lymph  glands  may  be  regarded  as  the  origin  of  the  immune 
body  in  cholera  and  typhoid  fever;  according  to  A.  AVassermann,  the 
medulla  of  bone  in  pneumonia.  In  the  medulla  of  bone  are  cells  which 
are  able  to  become  bound  with  bacteria.  (Cf.  Pyogenic  Diseases  of 
Bone.) 

Besides  these  specific  immune  bodies,  by  the  aid  of  which  the  com- 
plement dissolves  bacteria,  nmny  immune  sera  or  the  blood  of  sick  or 
convalescent  patients  contain  substances  wiiich  agglutinate  bacteria. 
These  substances  are  called  specific  agglutinins.  In  typhoid  fever  they 
are  found  in  the  blood  early  (Widal)  ;  they  are  also  found  in  tuberculosis 
(Koch)  and  in  staphylococcic  and  streptococcic  immune  sera,  etc. 

Experimentally,  not  only  specific  immune  bodies  for  bacteria,  but  also 
for  all  varieties  of  cells  of  another  species  may  be  produced,  for  red 
and  white  blood  corpuscles,  ciliated  epithelium,  and  spermatozoa.  These 
immune  sera  will  dissolve  the  cells  of  the  species  in  question  and  partly 
agglutinate  them.  As  a  result  of  this,  the  action  of  ha^molytic  (dissolv- 
ing red  corpuscles)  and  leucotoxic  (dissolving  w^hite  corpuscles)  sera  is 
fatal.     (Cf.  A.  Wassermann.) 

The  endotoxins  (bacterial  protoplasmic  poisons),  the  most  important 
poisonous  substances  of  pyogenic  bacteria,  are  absorbed  in  addition  to 
the  toxins.  The  organism  is  able  to  neutralize  certain  quantities  of  endo- 
toxins, but  it  is  unknown  in  what  way  this  is  accomplished. 

Action  of  Toxin  and  Endotoxin. — The  action  of  these  toxic  substances 
(toxin  and  endotoxin)  produced  by  bacteria  is  harmful,  excepting  the 
reactive  processes  which  produce  protective  substances.  The  results  of 
the  action  of  these  substances  diiTer,  depending  upon  the  tissues  in- 
volved, the  variety  of  toxin,  and  the  amount  produced.  The  results 
are  most  striking  in  tetanus,  in  which  the  clinical  picture  is  pro- 
duced by  the  direct  action  of  the  toxins  upon  the  cells  of  the  central 
nervous  system  oi-  in  the  toxic  neuritis,  resulting  in  paralysis,  w^hich 
occurs  in  diphtheria.  Cerebral  symptoms,  which  must  be  attributed  to 
the  action  of  toxins,  are  pronounced  in  many  acute  and  severe  infectious 
diseases  and  wound  infections.  Sometimes  these  are  confused  with  the 
symptoms  of  the  fever  and  are  regarded  as  constant  features  of  it. 
Other  changes  in  the  nervous  system,  such  as  myelitis,  neuritis,  neuralgia 


FEVER  1G3 

and  neuroses;  gastric  disturbances;  ami  ;ill)iiiiiiiiuri;i   ai-c  in  nil   proha- 
bility  due  to  the  action  of  toxins. 

Jlamolysis. — IMany  toxic  substances,  such  as  tliose  produced  l)y  the 
tetanus  bacilli,  strepto-  and  staphylococci,  dissolve  red  corpuscles,  and 
increased  amounts  of  urobilin  are  therefore  found  in  the  urine  in  these 
infections.  As  a  result  of  this  and  of  the  weakening  of  the  organism, 
anannia  occurs  in  chronic  suppuration  (osteomyelitis,  general  infection) 
and  in  chronic  diseases  (tuberculosis,  actinomycosis,  syphilis,  etc.). 
Parenchymatous  and  amyloid  degeneration  of  organs  (heart,  liver,  and 
kidneys)  are  also  due  partly  to  the  actioii  of  toxins. 

Literature. — Aschoff.  Ehrlichs  Seitenkettentheorie  und  ihre  Anwendung  auf 
die  kiinstlichen  Immunisierungsprozesse.  Zeitschr.  fiir  allgem.  Physiol.,  Bd.  1,  1902. 
— Behring.  Allgem.  Therapie  der  Infektionskrankheiten.  Urban  u.  Schwa rzenberg, 
1899. — Buchner.  Ueber  Immunitat.  Deren  natiiriiches  Vorkominen..  Miinch.  med. 
Wochenschr.,  1891,  p.  551. — Curschmann.  Zur  diagnost.  Beurteiliing  der  voni  Blind- 
darm,  etc.,  ausgehenden  entziindl.  Prozesse.  Miinch.  med.  Wochenschr.,  1901,  p. 
1907. — Friedberger.  Die  bakterizid.  Sera.  In  Kolle-Wassermanns  Ihindb.  der  path. 
Mikroorg.,  Bd.  4,  p.  452. — ■FrieJrich.  Die  aseptische  Versorgung  frischer  Wunden. 
Chir.-Kongr.  Verhandl.,  1898,  II,  p.  46. — Kuttner.  Diagnost.  Blutunter.suchungen 
bei  chirurg.  Eiterungen.  Chir.-Kongr.  Verhandl.,  1902,  I,  p.  126. — Lexer.  Zur  Behand- 
lung  akuter  Entziindungen  mittelst  Stauungshy]>eriimie.  Miinch.  med.  \\'ochenschr., 
1906,  p.  633. — Metschnikoff.  Die  Lehre  von  den  Phagozyten  und  deren  e.xperimentelle 
Grundlagen.  In  Kolle-Wassermanns  Handb.  der  path.  Mikroorg.,  Bd.  4,  p.  332. — 
Moxter.  Die  Beziehungen  der  Leukozyten  zu  den  bakterienauflosenden  Substanzen 
tierischer  Siifte.  Deutsche  med.  Wochenschr.,  1899,  p.  6S7. — Xotzel.  Ueber  d.  Bak- 
terienresorption  frischer  Wunden.  Arch.  f.  klin.  Chir.,  Bd.  60,  1900,  p.  25. — Oppen- 
heinier.  Die  Bakteriengifte.  In  Kolle-Wassermanns  Handb.  der  path.  Mikroorg., 
Bd.  1,  p.  344.— PaZtau/.  Die  Agglutination.  Ibid.,  Bd.  4,  p.  64:5.—Ri>mer.  Die 
Ehrlichsche  Seitenkettentheorie  und  ihre  Bedeutung  fiir  die  med.  Wissenschaftcn. 
Wien,  1904.— Sachs.  Die  Hiimolysine  und  ihre  Bedeutung  fiir  die  Inununitiitslehre. 
Wiesbaden,  1902. — Schimmelbusch  und  Richer.  Ueber  Bakterienresorption  frischer 
Wunden.  Fortschr.  der  Med.,  Bd.  13,  1895.— .4.  Wassermann.  Weitere  Mitteil.  iiber 
Seitenkettenimmunitat.  Berl.  klin.  Wochenschr.,  1898,  p.  209;— Wesen  der  Infektion. 
In  Kolle-Wassermanns  Handb.  der  path.  Mikroorg.,  Bd.  1,  p.  223;— Antitoxische 
Sera.  Ibid.,  Bd.  4,  p.  452; — Hiimolysine,  Cytotoxine  und  Priizipitine.  v.  ^'olkma^ns 
Samml.  klin.  Vortr.  Natur  Forscher,  No.  331.— TTVet/c.  Die  Ausscheitlung  von  Bak- 
terien  durch  den  Schweiss.     Chir.-Kongr.  Verhandl.,  1900. 


CHAPTER    IV 

FEVER 


All  the  reactive  processes  which  follow  the  absorption  of  bacteria 
and  their  toxins  have  for  their  object  the  control  of  the  infection.     The 
general  reaction  is  expressed  clinically  by  fever. 
13 


164       NATURE   OF   INFECTION;   LOCAL   AND   GENERAL   REACTION 

Symptoms  of  Fever. — The  chief  symptom  of  fever  is  an  elevation  of 
body  temperature.  The  normal  body  temperature,  when  taken  by  the 
mouth  is  98.6°  F.,  in  the  rectum  99.6°  F.  In  mild  fevers  the  temperature 
reaches  101°  F.  and  in  severer  ones  104°  F.,  or  even  1°  to  1.5°  higher. 
Disturbances  of  digestion  (anorexia,  vomiting)  ;  of  the  circulation  (rapid 
and  soft  pulse)  ;  and  of  the  respiration;  and  nervous  symptoms  (irrita- 
bility, headache,  disturbance  of  consciousness,  delirium)  often  accom- 
pany fever.  These  vary  with  the  temperature,  and  ai-e  caused  less  by 
fever  than  by  the  bacteria  which  produce  it. 

The  elevation  of  temperature  results  from  a  disturbance  of  the  equi- 
librium between  heat  production  and  heat  loss.  In  the  healthy  indi- 
vidual as  much  heat  is  lost  by  radiation  and  conduction  from  the  skin 
and  by  evaporation  from  the  skin  and  lungs,  as  is  produced,  for  example, 
by  oxidation  processes  occurring  in  the  muscles.  In  fever  the  production 
of  heat  is  increased,  and  the  amount  lost  is  not  sufficient  to  maintain  the 
equilibrium.  The  increased  production  of  heat  depends  upon  increased 
metabolism  and  oxidation  processes,  for  in  fever  the  amount  of  oxygen 
contained  in  the  expired  carbon  dioxid  (Liebermeister,  von  Ley  den)  is 
greater  than  that  which  is  inhaled  (Regnard,  Zuntz),  and  because  of 
the  increased  destruction  of  albumins  the  nitrogen  excreted  in  the  urine 
is  increased.  In  a  healthy  individual  increased  metabolism  (muscular 
effort)  does  not  produce  an  elevation  of  temperature,  because  the  ex- 
cessive heat  is  lost  by  radiation,  conduction,  or  evaporation. 

In  fever  the  processes  wdiich  eft'ect  this  are  disturbed.  The  loss  of 
heat  does  not  keep  pace  with  its  production.  There  is  interference  with 
the  loss  of  heat,  so  that  in  the  beginning  this  may  be  less  than  normal, 
and  thus  there  is  produced  a  heat  congestion  (Traube). 

According  to  Krehl,  it  is  most  probable  that  the  substances  which 
produce  fever  incite  abnormal  decomposition  processes.  Thus  there  is 
produced  an  increase  in  the  decomposition  and  oxidation  of  albumins 
which  interferes  with  the  loss  of  heat.  It  may  be  that  the  stimulus  which 
excites  heat  loss  is  deficient,  or  that  the  mechanism  (blood  vessels,  sweat 
glands,  and  breath)  which  effects  it  functionates  poorly,  or  finally  that 
the  regulating  center  in  the  brain  is  at  fault. 

A  sudden  rise  of  temperature  (stadium  incrementi)  is  often  ac- 
companied by  a  feeling  of  chilliness  or  a  rigor.  The  amount  of  heat 
lost  is  diminished,  while  the  production  of  heat  is  increased  in  this 
stage.  The  cajjillaries  of  the  skin  are  contracted  by  the  action  upon 
the  va.somotoi-  centers  of  the  fever-producing  substances.  Reflex  mus- 
cular twitchings  may  occur  and  give  rise  to  the  clinical  picture  of  a 
chill. 

in  the  climax  (fastigium)  which  follows  afterone  to  two  hours,  the 
skin  is  white,  dry,  and  somewhat  injected.     The  amount  of  heat  lost  is 


FEVER  105 

relatively  increased,  but  not  enough  is  lost  to  bring  about  a  return  to  the 
normal  condition. 

The  fall  of  the  fever  (stadium  decrementi)  is  frequently  accompanied 
by  maz'ked  sweating  and  sometimes  by  symptoms  of  collapse.  Heat  is 
not  formed  in  such  large  amounts,  while  the  loss  of  heat  is  effected  in 
a  number  of  different  ways.  If,  during  an  infection,  the  organism  be- 
comes weakened  and  its  resistance  decreases,  the  temperature  falls;  for 
example,  if,  as  a  result  of  cardiac  weakness,  sufficient  heat  is  not  pro- 
duced.    Collapse,  which  frerfuently  proves  fatal,  may  then  develop. 

Surgical  Significance  of  Fever. — 1.  Particular  fever  curves  give  to 
many  infections  a  characteristic  impress  which  is  of  great  diagnostic 
importance.  2.  An  elevation  of  temperature  indicates  some  irregularity 
in  wound  repair,  the  beginning  of  invasion  by  micro-organisms  or  the 
accumulation  of  inflammatory  products. 

Causes  of  Fever. — The  fact  that  the  temperature  rises  with  the 
development  of  an  abscess  or  with  the  beginning  of  suppuration  or 
putrefaction  in  a  wound,  and  that  it  subsides  when  the  pus  is  permitted 
to  escape  or  the  inflammation  subsides,  is  proof  that  the  substances  pro- 
ducing the  fever  result  from  the  inflammation  or  are  contained  in  the 
wound  secretion.  At  a  time  Mhen  little  was  known  about  bacteria,  and 
nothing  was  known  about  their  action,  experiments  were  made  with 
putrefactive  wound  secretions  and  the  decomposition  products  of  ani- 
mals and  plants  (Billroth,  AVeber,  von  Bergmann)  to  determine  the 
cause  of  fever  following  wound  infections. 

Not  only  the  decomposition  products  from  suppurative  and  putrefac- 
tive foci,  but  a  number  of  other  substances  which  produce  an  increased 
decomposition  of  albumins  (Krehl)  cause  fever.  All  ferments  (fibrin 
ferment,  according  to  von  Bergmann  and  Angerer),  poisonous  albumi- 
nous substances,  the  decomposition  products  of  cells  (h:i'nioglol)in),  for- 
eign constituents  of  the  blood  (cells  and  serum)  of  man  and  animals,  and 
especially  the  toxins  of  pathogenic  bacteria  cause  fever. 

Relation  of  Fever  to  Absorption  of  Toxins. — Decline  Due  to  Proicc- 
tive  Substances. — It  has  been  demonstrated  by  experiments  upon  ani- 
mals and  man  and  by  clinical  experience  that  the  diffusion  of  the  toxins 
of  pathogenic  bacteria  in  the  body  produces  fever,  and  that  the  decline 
of  the  fever  follows  the  development  of  protective  substances  in  the 
blood.  The  fever  in  diphtheria  subsides  as  soon  as  antitoxin  is  injected, 
while  after  the  crisis  in  pneumonia  pi-otective  substances  are  present  in 
the  blood.  Depending  upon  whether  the  antibodies  are  developed  ([uiekly 
or  slowly,  the  fall  of  temperatuir  is  sudden  (critical)  or  gradual  (lytic). 

In  continuous  fever,  in  which  the  ditVei-enee  b<'tw(>en  tbe  maxinnun 
and  minimum  rises  of  temperature  taken  moi-ning  and  evening  is  at  most 
one  degree,  the  poisonous  products  of  the  bacteria  predominate  over  anti- 


166       NATURE   OF    INFECTION;    LOCAL   AND   GENERAL   REACTlOxM 

bodies.  In  intermittent  fever,  in  which  there  are  intervals  of  days  with- 
out fever,  antibodies  are  formed  intermittently,  are  then  exhausted,  and 
allow  the  newly  formed  toxins  to  act.  The  same  holds  true  for  remit- 
tent fever  in  which  the  fever  falls  in  the  morning. 

The  different  forms  of  fever  curves  in  the  different  infections  depend 
upon  the  bacteria  producing  the  infection,  the  toxins  which  are  formed 
in  the  tissues,  and  the  products  of  decomposition  (ferments  in  the  exu- 
date, dead  tissues  which  are  dissolved)  resulting  from  the  inflammation. 
For  this  reason  many  diseases  have  typical  fever  curves,  in  which  a 
high  fever  persists  for  a  certain  time  and  then  falls;  in  pneumonia  and 
erysipelas,  for  example,  in  about  one  week  the  organism  overcomes  the 
infection  by  oxidizing  the  products  of  decomposition  and  by  producing 
protective  substances.  - 

The  examination  of  the  cells  (medulla  of  bone,  spleen,  and  lymph 
glands)  of  an  organism  which  has  foi-med  bactericidal  bodies  in  a  num- 
ber of  infections  will  reveal  increased  cellular  activity,  as  indicated 
by  relatively  numerous  karyokinetic  figures  (Pfeift'er,  Marx,  A.  Wasser- 
mann,  Freynuith),  showing  that  an  effort  has  been  made  in  this  way 
to  overcome  the  infection. 

Fall  of  Fever  etfter  Incision  of  Abscess,  Amputations,  etc. — The  fall 
of  temperature  after  the  incision  of  a  phlegmon  or  abscess  or  after  the 
amputation  of  a  sujipurating  extremity  indicates  that  the  toxins  and 
products  of  decomposition  are  no  longer  being  absorbed.  If  the  fever 
rises  again,  it  indicates  that  new  tissue  is  being  invaded  or  that  the  dis- 
charge of  pus  is  prevented.  If  the  infection  is  not  controlled  by  incision 
or  amputation  the  fever  continues  until  death,  the  overwhelming  infec- 
tion producing  continuously  new  toxins  before  sufficient  protective  sub- 
stances are  formed  to  prevent  their  fatal  action  {vide  p.  156). 

Loiv  Fever  in  Fatal  Infections. — Fever  may  be  absent  or  slight  in 
fatal  infections.  Because  of  the  virulence  of  the  bacteria  or  the  weak- 
ness of  the  organism  (old  people)  there  is  no  general  reaction.  In  ani- 
mal experiments  there  is  often  no  fever  after  the  injection  of  large  fatal 
doses  of  toxins,  but  subnormal  temperature  and  collapse.  Fever,  there- 
fore, not  only  indicates  the  beginning  and  extension  of  severe  infection, 
but  indicates  during  its  entire  course  the  activity  of  those  processes  which 
combat  infection. 

Some  importance  lins  justly  been  attributed  to  the  harmful  action 
which  fever  exerts  upon  bacteria.  Many  bacteria,  particularly  the 
gonococci,  are  killed  when  exposed  to  high  temperature.  The  conditions 
in  the  culture  tube,  however,  are  not  comparable  to  those  in  the  living 
body,  for-  iti  llic  roniici-  llic  bnctcri;)  are  exposed  to  the  desiccating  action 
of  the  ail-,  and  l"or  this  ccasoii  this  supposed  action  of  fever  is  doubtful 
(A.  AVassermann), 


FEVER  167 

Action  of  Antipyretics. — The  more  one  considers  the  value  of  the 
febrile  reaction,  which  was  claimed  l)y  llip|)()crates,  but  wliich  has  been 
doubted  more  recently,  the  less  one  is  inclined  to  prescribe  chemical 
agents  (antipyretics)  to  control  the  fever.  One  fears  that  they  will 
interfere  with  the  production  of  protective  snl)stances,  although  Schiitze 
has  demonstrated  at  least  for  typhoid  fever  that  antibodies  are  formed 
even  when  the  temperature  is  reduced  by  antipyrin.  The  surgeon  should 
not,  however,  use  antipyretics  to  reduce  the  fever,  for  next  to  the  general 
appearance  of  the  patient,  it  is  the  most  important  index  of  the  condition 
of  the  wound  or  inflammatory  focus. 

Aseptic  Fever. — A  non-infectious  or  aseptic  fever  (Genzmer  and  von 
Volkmann)  is  distinguished  from  fever  resulting  from  the  absorption 
of  infectious  substances,  especially  bacterial  toxins.  This  fever  occurs 
after  subcutaneous  injuries,  especially  after  fractures ;  with  vascular  sar- 
comas; when  there  is  extravasation  of  large  quantities  of  blood  into  the 
tissues ;  and  after  injuries  of  certain  parts  of  the  brain.  It  does  not  occur 
constantly,  however,  and  differs  clinically  from  the  infectious  fever  in  the 
absence  of  a  chill  and  general  febrile  symptoms.  The  pulse  is  good  and 
only  slightly  accelerated,  and  there  is  but  little  elevation  of  temperature 
(100°  F.,  rarely  higher). 

This  fever  is  caused  by  the  formation  and  absor^jtion  of  pyi-ogenie 
substances  from  blood  exudates  and  dead  tissue.  Earlier  it  was  sug- 
gested by  Alex.  Schmidt,  von  Bergmann,  and  von  Angerer  that  the 
fever  was  caused  by  the  fibrin  ferment.  According  to  the  later  investi- 
gations of  Schnitzler  and  Ewald,  it  is  produced  by  the  nucleins,  albu mi- 
noses,  and  allied  substances. 

The  elevation  of  temperature  after  injury  of  the  brain  is  caused  by 
a  disturbance  or  irritation  of  certain  parts  of  this  organ  (e.  g.,  medial 
part  of  the  corpus  striatum).  It  may  be  pi'oduced  experimentally  ( lieat 
puncture). 

A  slight  elevation  of  temperature  without  other  symjitoms  of  fever 
occurs  frequently  after  operation-  and  open  wounds  (also  after  cliild- 
birth),  although  there  is  no  irregularity  in  wound  repair.  This  has 
been  spoken  of  as  aseptic  fever,  and  the  absorption  of  the  decomposition 
products  of  injured  tissue  and  of  blood  exudates  has  been  regarded  as 
the  cause  (von  Volkmann).  The  demonstration,  however,  of  bacteria 
in  accidental-  and  operation-wounds  which  heal  without  inflammation, 
likewise  the  demonstration  of  slightly  virulent  pathogenic  bacteria  upon 
hands  which  have  been  thoroughly  sterilized,  upon  the  sterilized  skin  of 
the  patient,  in  the  air,  etc.,  indicate  that  bacteria  are  an  important 
factor  in  so-called  aseptic  fever  following  operation-  and  accidental- 
wounds,  even  M^hen  the  wound  repair  pursues  an  aseptic  course.  Used 
in  this  sense,  Volkmann 's  designation,  aseptic  fever,  may  still  be  retained. 


168      NATURE  OF   INFECTION;  LOCAL  AND  GENERAL  REACTION 

A  purely  nervous  fever,  due  to  an  irritation  of  the  central  nervous  sys- 
tem (heat  center),  occurs  in  insanity  and  psychoses,  particularly  in  pare- 
tic dementia  and  hysteria. 

Literature.- — -v.  Bergmann  und  Angerer.  Das  Verhaltnis  der  Ferment intoxikation. 
Festschr.  d.  Wiirzburger  Universitiit,  1882. — Brunner.  Wundinfektion  und  Wiindl)t'- 
handlung,  I,  Frauenfeld,  1898. — Freymuth.  Exjj.  LTntersuch.  iiber  d.  Beziehungen 
leichter  Infekt.  z.  blutbild.  Apparat.  Deutsche  med.  Wochenschr.,  1903,  p.  350. — 
Genzmer  und  Volkmann.  Sept.  u.  asept.  Wundfieber.  v.  Volkmanns  Samml.  klin. 
Vortr.,  No.  I21.—Krehl.  Das  Fieber.  Path.  Physiol.,  Leipzig,  1904:.— Adolf  Schmidt. 
Lehrbuch  der  allgem.  Path,  und  Ther.  innerer  Krankheiten.  BerHn,  1903. — Schnitzler 
und  Eivalil.  Beitrag  zur  Kenntnis  des  aseptischen  Fiebers.  Arch.  f.  klin.  Chir.,  Bd. 
53,  1896,  p.  530. — Unverricht.  Ueber  das  Fieber.  v.  Volkmanns  Samml.  klin.  Vortr., 
Natur  Forscher,  No.  159,  1896. — A.  Wasserniann.  Wesen  der  Infektion.  In  Kolle- 
Wassermanns  Handb.  der  path.  Mikroorg.,  Bd.  1,  1903,  p.  223. 


II.    WOUND    INFECTIONS     PRODUCED    BY 

PYOGENIC    AND    PUTREFACTIVE 

BACTERIA    AND    THEIR 

RESULTS 

A  number  of  different  varieties  of  bacteria  are  found  in  wound 
infections.  Those  producing  suppurative  inflammation  are  grouped  as 
pyogenic  bacteria.  Closely  allied  to  these,  and  often  associated  witli 
them,  are  the  putrefactive  bacteria.  A  second  large  group  incliulis  those 
bacteria  which  produce  specific  diseases  (cf.  2,  Part  III). 

The  pyogenic  bacteria  are  divided  into  those  which  produce  suppura- 
tive inflammation  (pyogenic  cocci),  and  those  which  rarely  produce  pus, 
but  more  frequently  other  forms  of  inflammation  or  specific  diseases 
(pneumoeocci,  gonococci,  bacterium  coli  commune,  bacillus  pyocyaneus, 
typhoid  bacilli).  No  pyogenic  bacteria  are  exclusively  pyogenic,  on  the 
other  hand  they  are  all  phlogogenous — that  is,  they  produce  inflamma- 
tion which,  with  some  more  frequently  than  with  others,  ends  in  sup- 
puration. 


CHAPTER    I 

THE    MOST    IMPORTANT   PYOGENIC    BACTERIA 

The  first  microscopic  demonstration  of  minute  living  matter  in  pus 
is  ascribed  to  0.  Weber  (1863)  and  Rindfleisch  (1866),  Later  von  Reck- 
linghausen, Waldeyer,  and  Klebs  (1871),  Orth  (1872),  Birch-IIirschfeld 
(1873)  discovered  micrococci  in  pya-mia,  septica'mia,  puerperal  fever, 
and  suppurative  inflammation.  In  1874  Billroth  described  another  form, 
his  cocco-bacteria  septica. 

R.  Koch  was  the  first  to  make  an  accurate  study  of  the  pyogenic  bac- 
teria, and  his  work  on  wound  infections  (1878)  laid  the  foundation  of 
modern  bacteriology,  and  the  isolation  and  cultivation  of  different  varie- 
ties of  bacteria  began  with  the  introduction  by  him  of  transparent,  firm 
culture  media  (1881).  Ogston  (1880-82)  described  the  microscopic 
appearance  of  cocci  found  in  pus,  and  differentiated  streptococci  from 

169 


170 


WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 


staphylococci.  In  1883  Becker,  following  Koch's  directions,  obtained 
in  pure  culture  a  yellow  staphylococcus  from  a  case  of  osteomyelitis,  and 
Fehleisen  a  streptococcus  which  caused  erysipelas.  Pure  cultures  of  a 
number  of  different  varieties  of  cocci  were  obtained  by  Rosenbach  (188-1:) 
and  Passet  (1885)  and  differentiated  from  one  another,  and  their  etio- 
logical significance  in  the  inflammatory  processes  associated  with  them 
recognized. 

(a)     STAPHYLOCOCCI 

(Spherical  fissioti-fiingi,  occurring  usually  in  grape-shaped  colonies;  from  (rTa<i)vKi\, 

meaning  grape.) 

The  staphylococcus  pyogenes  aureus  was  first  obtained  in  pure  cul- 
tures by  Becker ;  later  by  Rosenbach.     The  cocci  occur  mostly  in  groups, 

rarely  singly  or  in  pairs  (Fig.  89). 
They    stain   readily   with   basic 
aniline  dyes,  and  are  not  destained 
by  Gram's  method. 

They  grow  upon  ordinary  cul- 
ture media,  appearing  in  gelatin 
after  from  thirty-six  to  forty-eight 
hours  as  small  white  points,  in  stab 
cultures  as  a  grayish  white  deposit. 
On  the  third  day  the  gelatin  be- 
comes liquefied,  and  the  colonies 
assume  a  yellowish  color.  The  en- 
tire culture  medium  is  liquefied  in 
three  wrecks. 

Upon   agar,   after  standing  for 

twenty-four  hours  in  the  incubatoi-, 

they  appear  as  round  white,  later  as  golden  yellow,  colonies;  the  culture 

medium  is  not  licjuefied.     They  develop  similarly  upon  blood  serum  and 

potato.     Bouillon  is  clouded. 

The  cocci  are  very  resistant,  and  withstand  drying  for  some  days. 
After  remaining  in  cultures  for  over  a  year  they  are  able  to  develop, 
and  only  after  being  exposed  to  a  temperatui'e  of  80°  C.  for  a  quarter  of 
an  hour  are  the.y  killed  (von  Tiingelsheim). 

The  yellow  staphylococci  are  widely  distributed. 
They  may  be  found  alone,  or  associated  with  other  bacteria  in  all 
forms  of  suppuration  or  general  infection  in  man,  and  they  are  able 
to  develop  after  being  encapsulated  in  bone  for  a  number  of  years. 
They  pass  into  the  blood  and  fre(juently  produce  inflammatory  foci  in 
young  bones;  tliis  is  partly  du(^  to  the  jx'culiar  way  in  which  they  grow, 
as  lliey  funii  elnmi)s  which  may  ocelnde  the  cajiijlaries. 


Fig.  89. 


THE   MOST   IMPORTANT   PYOGENIC   BACTERIA  171 

They  are  found  in  the  skin,  the  hair,  and  upon  mucous  membranes. 
A  wide  area  of  skin  surrounding  small  pustules,  furuncles,  or  a  suppu- 
rating wound  is  infected  with  pyogenic  cocci.  They  may  be  found  upon 
a  surgeon's  hands  who  daily  comes  in  contact  willi  pus  or  infectious 
materials.  They  are  found  upon  the  mucous  membranes  of  the  upper 
respiratory  passages,  without  giving  rise  to  inthimmation  (]\Iiller),  occur- 
ring especially  in  the  saliva,  in  the  crypts  of  the  tonsil,  in  the  coating 
of  the  tongue,  and  upon  the  nasal  nnicous  membranes.  They  can  be 
transferred  to  the  air  in  small  particles  of  mucus,  which  are  discharged 
in  speaking,  clearing  the  throat,  coughing,  and  sneezing  (Fluegge). 
Apparently  they  find  favorable  conditions  for  growth  in  the  buccal 
cavity  of  man.  They  disappear  in  a  few  days  when  transferred  to 
animals — e.  g.,  to  the  buccal  mucous  membrane  of  the  ra])l)it   (Lexer). 

Usually,  however,  staphylococci  found  upon  healthy  mucous  mem- 
branes are  attenuated.  They  may  be  carried  by  the  food  without  loss 
of  virulence  into  the  gastrointestinal  canal,  and  in  case  of  perforation 
or  circulatory  disturbances  (contusion,  invagination,  or  strangulation) 
cause  peritonitis,  or,  usually  associated  with  other  bacteria,  intlanniiation 
about  the  rectum  (periproctitis).  They  are  frequently  found  in  the 
conjunctival  sac  and  upon  the  vaginal  mucous  membrane. 

They  are  found  upon  objects  surrounding  num,  and  are  especially 
numerous  when  one  is  unclean  in  the  treatment  of  a  suppurating 
focus  or  inflamed  mucous  membrane;  being  then  found  in  the  linen, 
in  pocket  handkerchiefs,  and  on  all  objects  with  which  the  patient 
comes  in  contact.  They  have  been  demonstrated  in  the  dust  of  the 
street,  in  the  air  of  hospitals,  but  not  in  the  earth  or  in  unconfined  air 
(Passet). 

The  staphylococcus  aureus  rarely  occurs  spontaneously  in  animals. 
They  have  been  found  in  osteoarthritis  in  geese  (Lucet),  in  osteomyelitis 
in  cattle  (Haas)  and  horses  (Frohner)  and  in  mastitis  in  cows. 

They  differ  in  virulence,  both  in  Avound  infections  and  in  infection 
produced  in  animal  experimentation.  The  virulence  of  cocci  is  increased 
by  transmitting  them  through  different  animals. 

Rabbits  and  guinea  pigs  are  susceptible ;  mice  and  dogs,  cows,  horses, 
and  goats  are  less  so.  Cutaneous  inoculations  are  only  successful  wIumi 
the  cocci  are  highly  virulent  (after  cultivation).  Subcutaneous  injec- 
tions are  followed  by  the  formation  of  encapsulated  abscesses  containing 
thick  pus.  Usually  the  inflammatory  process  is  not  progressive.  Fatal 
infections  are  produced  only  by  the  injections  of  cultures  into  the  pleura, 
peritoneum,  or  blood  vessels.  Animals  die  after  intravenous  injections 
in  from  one  to  eight  days,  and  suppurating  foci  are  then  found  in  tht^ 
muscles,  viscera,  and  joints  (in  young  animals  foci  in  bones  are  found 
especially   frequently,   Rodet).      If  attenuated   cultures   are   used,    the 


172  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

animals  run  a  temperature  and  are  sick  for  a  short  time,  often  de- 
veloping a  chronic  suppurative  osteomyelitis  of  one  or  more  bones 
(Lexer). 

It  is  important  to  determine  the  pathogenicity  of  the  different  staphy- 
lococci (e.  g.,  those  upon  the  skin  of  sterilized  hands,  in  nonpurulent 
wound  secretion,  in  the  saliva  and  air).  At  the  present  time  there  is  no 
method  which  can  be  relied  upon.  Animal  experiments  cannot  be  relied 
upon,  as  the  susceptibility  of  animals  and  the  virulence  of  the  cocci  vary. 
The  serodia gnostic  test  of  Kolle  and  Otto  may  prove  of  value  in  this 
connection  {vide  below). 

The  toxins  of  staphylococci  are  of  two  kinds :  The  toxin  (staphylo- 
toxin) demonstrable  in  culture  filtrates  and  in  inflammatory  exudates 
produces  local  necrosis  and  suppuration  and  general  toxic  symptoms. 
It  is  destroyed  when  heated  to  60°  C.  It  is  toxic  for  leucocytes  (van  de 
Velde)  and  dissolves  red  blood  corpuscles,  and  must  therefore  contain 
a  leucocidin  as  well  as  a  haemolysin  (ha^motoxin)  (Neisser  and  Wechs- 
bcrg).  The  second  is  a  protoplasmic  toxin  (endotoxin),  which  is  bound 
to  the  bacterial  cell,  and  is  found  only  after  the  bacteriolysis  of  large 
quantities  of  staphylococci  (von  Lingelsheim). 

Staphylococci  also  form  ferments  which  digest  albumen  and  gelatin. 

Attempts  at  innnunization  have  given  no  practical  results,  although 
some  have  succeeded  in  different  ways  in  immunizing  animals,  and  have 
obtained  from  them  a  serum  which  was  active  in  normal  animals  (von 
Lingelsheim ) . 

Kolle  and  Otto  have  used  the  blood  serum  of  rabbits  which  had  been 
immunized  with  large  quantities  of  dead  cultures  of  staphjdococci  to 
differentiate  the  pathogenic  from  the  saprophytic  varieties.  The  serum 
of  an  immunized  animal  has  the  property,  even  in  dilutions  of  1  to  100, 
to  agglutinate  in  a  short  time  pathogenic  bacteria.  [Serums  obtained  by 
immunization  with  pathogenic  strains  have  a  much  higher  agglutinating 
poM'er  for  these  strains  than  for  nonpathogenic  varieties,  and  the  con- 
verse is  also  true. — Ricketts'  "  Infection,  Innnunity,  and  Serum  Ther- 
apy/' P-  383.]  Nonj^atbegonic  varieties  are  not  agglutinated  by  serum 
obtained  by  immnrii/atioii  with  ]>atbogenic  varieties.  Nevertheless  the 
testing  of  the  agglutitiating  propci-ties  of  human  serum  is  not  used  to 
determine  wbetlicr  the  disease  is  produccnl  by  staphylococci  or  not,  as  the 
serum  contains  staphyloagglutinin  not  only  in  pui'c  staphylococcic  infec- 
tions, but  also  ill  infections  in  which  they  are  secondary  to  some  other  va- 
riety of  bacteria  (Beitzke).  The  formation  of  antiha'molysins  has  also 
been  used  for  diagnostic  purposes.  According  to  Neisser  and  Wechsberg, 
an  antitoxin  is  developed  for  the  staphyloha'iiiolysin  (staphylolyshi). 
This  antitoxin,  which  is  called  antilueniclysin  or  antilysin,  prevents  the 
action  (»r  the  lysin.     Jji-uek,  IMichaelis,  and  E.  Schultze   found  that   in 


THE  MOST   IMPORTANT  PYOGENIC   BACTERIA  173 

staphylocdccic  iulVct  ions  the  jintilysiii  ('(Hitciil  l'n(|ii.iit  ly,  l)uj  iml  always, 
c'XCH'ecU'd  ('(tnsi(lcral)ly  tliat  nl'  tlic  scniiii  of  a  hcallliy  man. 

The  staphylococcus  pyogenes  albus  was  first  cultivatiMl  hy  Kosoiil)aeh. 
It  differs  from  the  aureus  in  that  its  cultures  remain  white.  It  is  found 
more  frecjuently  than  the  aureus  as  the  cause  of  mild  inflammations, 
combined  with  which  it  usually  causes  severe  inflanunation.  It  is  found 
almost  constantly  upon  the  skin,  and  frcfjuently  produces  suppuration 
about  stitch  holes  and  mild  wound  complications.  The  staphylococcus 
albus  may  be  demonstrated  constantly  in  the  skin  of  the  hands  {vide 
Hand  Sterilization,  Part  I),  and  frequently  upon  accessible  nuicous  mem- 
branes. Notwithstandintj;  the  fact  that  it  occurs  much  more  rarely  than 
the  aureus  in  severe  suppurative  processes  (excepting  the  double  infec- 
tion with  both  varieties),  it  should  be  remembered  that  it  may  produce 
severe  inflammatory  changes,  even  fatal  general  infections. 

In  animal  experiments  it  does  not  differ  from  the  aureus. 

The  staphylococcus  pyogenes  citreus  (Passet),  characterized  by  its 
color,  likcAvise  the  staphylococcus  cereus  albus  and  flavus,  character- 
ized by  the  waxy  appearance  of  their  white  or  yellow  colonies,  are  of 
much  less  importance.  They  are  only  rarely  found  in  human  pus. 
(Hentschel  found  the  staphylococcus  citreus  in  a  fatal  infection  follow- 
ing a  furuncle  of  the  lip  in  the  pus.  blood,  and  in  the  spleen.  Jacobitz 
also  found  them  in  a  general  infection.) 


(b)     STREPTOCOCCI 

{Streptococci  are  fission-fungi  occurring  in  chains  or  pairs.) 

The  streptococcus  of  erj'sipelas  discovered  by  Fehleisen  in  1881  and 
cultivated  by  him  in  1883,  and  the  streptococcus  pyogenes  cultivated  by 
Rosenbach  in  1884  are  not  to  be  regarded  as  specific  for  any  diseased 
process,  but  as  closely  related.  Classifications  based  upon  pathological 
and  clinical  symptoms  are  unreliable,  as  any  streptococcus  independent 
of  its  origin  may,  under  certain  conditions,  produce  any  form  of  inflam- 
mation which  is  peculiar  to  streptococcic  infections.  ]\Iild  suppuration 
or  severe  general  infection  may  be  pi-oduced  by  the  streptococci  of  ery- 
sipelas, while  other  varieties  of  streptococci,  although  not  derived  from 
an  erysipelatous  focus,  may  produce  erysipelas  (Petruschky).  The  clini- 
cal picture  does  not  depend  upf)n  the  variety  of  streptococci,  but  n\)ou 
a  number  of  different  factors,  among  which  the  virulence  of  the  bacteria 
and  the  susceptibility  of  the  patient  are  the  most  important.  The  many 
transitions  in  the  clinical  forms  of  streptococcic  infections  are  explain. 'd 
in  this  way. 

Depending  upon  the  cultural  differences  upon  definite  cultui-e  media 


174 


WOUND    INFECTIONS   PRODUCED   BY   BACTERIA 


i'i< 


1)0. 


(blood  agar,  litmiis-metrose  agar),  Scliottiniu'Uer  and  Eiig.  Fraenkel 
have  differentiated  three  varieties  of  streptocoeei  which  are  pathogenic 
for  man.  Of  how  much  bacteriological  and  clinical  importance  this  dis- 
tinction is,  must  be  determined  by  later  investigations. 

Streptococci  are  spherical  or  somewhat  flattened,  have  no  movement 
of  their  own,  and  are  slightly  larger  than  staphylococci.     They  always 

divide  in  the  same  direction,  and 
the  characteristic  slightly  tortuous 
chains  of  from  eight  to  twenty  cocci 
are  formed  in  this  way  (Fig.  90). 
Diplocoecic  forms  are  found  only 
in  the  tissues,  inflammatory  exu- 
dates, in  the  blood,  especially  in 
severe  inflammatory  processes,  and 
these  become  transformed  in  cul- 
ture media  into  long  chains. 

They  stain  with  aniline  dyes, 
and  according  to  Gram's  method. 
Streptococci  may  be  most  easily 
cultivated  upon  agar  and  blood  se- 
rum. After  twenty-four  hours  (in 
the  incubator)  small,  round,  some- 
what transparent,  closely  approximated  colonies  develop,  which  do  not 
become  much  larger  during  later  growth.  Upon  gelatin  (at  room  tem- 
perature) they  develop  much  more  slowly;  small,  transparent  drops  de- 
veloping after  a  number  of  days ;  a  delicate  white  deposit  forming  along 
the  tract  in  stab  cultures.     Gelatin  is  not  liquefied. 

Bouillon  is  clouded  by  one  variety  of  streptococci,  while  a  flocculent 
deposit  is  formed  by  another  at  the  bottom  of  the  media. 

The  streptococci  become  attenuated  or  die  after  a  few  days  upon 
any  kind  of  culture  media,  so  that  they  must  be  transferred  daily  if  their 
vii'ulence  is  to  be  preserved.  It  is  simpler  to  use  Petrusehky's  method 
in  maintaining  virulence,  in  which  two-days-old  stab  cultures  are  kept  in 
an  ice  chest  and  the  same  virulence  is  maintained  for  months.  Strepto- 
cocci are  particularly  resistant  against  drying.  They  can  even  be  dried 
upon  blotting  paper  for  some  time  and  still  retain  virulence  (Pe- 
truschky).  The  cocci  are  destroyed  in  cultures  which  are  heated  for  an 
hour  at  from  70°  to  75°  C. 

Streptococci  are  as  widely  distributed  outside  of  the  body  as  staphy- 
lococci. However,  it  is  more  difficult  to  demonstrate  them  on  man,  in 
the  air  of  hospital  wards  and  operating  rooms,  upon  objects,  skin,  and  mu- 
c(ms  membrane,  as  they  are  overgrown  by  other  varieties  of  bacteria  upon 
culture  media.     They  are  found  in  the  same  places  as  the  staphylococci. 


THE   MOST   IMPORTANT   PYOCiEXIC    BACTERIA  175 

The  frequency  of  erysipelas  and  puerperal  sepsis  in  preantiseptie 
times  indicates  how  easily  virulent  streptococci  may  be  transferred  to 
wounds  or  to  the  vagina  and  uterus  by  unsterilized  hands  and  in- 
struments. 

Their  frequent  occurrence  in  the  upper  air  passages  upon  healthy 
as  well  as  upon  slightly  or  severely  infiamed  mucous  mem])ranes  sliows 
that  they  find  favorable  conditions  for  growth  here.  But  their  presence 
alone  is  not  sufficient  to  produce  pathological  changes;  other  factors  are 
necessary,  such,  for  example,  as  an  increase  of  virulence  resulting  from 
putrefactive  processes  or  decrease  in  local  resistance  from  chilling  or 
some  injury. 

Virulent  streptococci  are  expelled,  especially  in  catarrh,  from  tin; 
buccal  and  nasal  cavity  with  forcibly  expired  air  (in  coughing  and 
sneezing),  or  they  are  carried  by  the  saliva  and  food  into  the  stomach, 
where  they  are  not  always  destroyed  by  the  gastric  juice.  The  develop- 
ment of  streptococcic  peritonitis  following  perforation  of  the  gastro- 
intestinal tract  due  to  subcutaneous  rupture  or  ulceration,  the  finding  of 
streptococci  in  the  pus  of  appendiceal  abscesses  and  in  the  exudate  in 
the  sac  of  a  strangulated  hernia  demonstrate  conclusively  that  strepto- 
cocci are  carried  by  the  food  into  the  intestines. 

Streptococci  are  found  in  many  different  inflammatory  processes,  and 
are  frequently  associated  Avith  staplndococci.  If  the  streptococci  act 
alone,  a  serous  exudate  into  the  tissue  is  in  the  beginning  the  most 
marked  feature  of  the  inflammation.  Erysipelas  is  usually  a  serous  in- 
flammation. Frequently  in  the  severe  progressive  phlegmon  due  to  the 
streptococci,  only  a  few  insignificant  purulent  foci  develop  within  the 
inflammatory  oedema,  necrosis  of  the  connective  tissues  usually  occurring 
rapidly  and  becoming  extensive.  ]\Iild  suppurative  ])rocesses  are  rarely 
caused  by  streptococci.  Severe  general  symptoms  develop  much  more 
frequently  from  small  cutaneous  wounds  infected  with  streptococci  than 
from  similar  infections  with  staphylococci. 

Streptococci  may  be  found  in  all  the  inflammatory  processes  which 
are  produced  by  staphylococci.  They  are  found  much  less  frequently, 
however,  in  furuncles  and  osteomyelitis.  Mixed  infection  with  the  sti-cji- 
tococcus,  such  as  occurs  in  tuberculosis  of  the  lungs,  diphtheria,  typhoid 
fever,  and  putrefactive  inflammation,  alwaj^s  adds  to  the  gravity  of  the 
prognosis. 

The  virulence  of  streptococci  varies  within  wide  limits  in  man  as  wt>ll 
as  in  susceptible  animals.  The  difference  in  clinical  pictures  is  largely 
dependent  upon  this  fact,  partly  also  upon  the  kind  of  infection  and 
the  individual  resistance,  which  may  be  reduced  ])y  disease  (tubercu- 
losis, influenza,  diphtheria).  The  clinical  pictures  of  streptococcic  infec- 
tions differ  even  in  healthy  individuals,  as  the  inoculation  experiments 


176  WOUND   LNFECTIONS   PRODUCED   BY   BACTERIA 

of  Koch  and  Petriisehky  have  demonstrated.  Streptococci  may  be  atten- 
uated by  passage  through  another  species ;  for  example,  streptococci  from 
a  rabbit  may  be  attenuated  for  this  animal  by  passing  them  through  a 
mouse  (Knorr).  Streptococci  derived  from  man  are  therefore  the  most 
dangerous  in  human  wound  infections.  This  agrees  with  clinical 
experience. 

White  mice  and  rabbits  are  the  most  susceptible  of  experimental  ani- 
mals. The  former  succumb  in  from  one  to  six  days  of  a  general  infec- 
tion after  subcutaneous  or  intraperitoneal  injections  of  small  amounts 
of  streptococcic  cultures.  In  rabbits  the  different  grades  of  virulence  of 
streptococci  are  indicated  in  the  following  way :  In  infection  of  the  wound 
of  the  ear  with  slightly  virulent  cocci,  an  erysipelas  of  moderate  severity 
develops;  while  if  highly  virulent  cocci  are  used  a  general  infection 
without  any  local  changes  develops  which  proves  fatal  in  from  twenty- 
four  to  forty-eight  hours.  Different  degrees  of  virulence  may  be  pro- 
duced in  streptococci  of  different  origin  by  artificially  increasing  or 
decreasing  their  virulence. 

AYhen  an  animal  dies  some  days  after  the  inoculation,  streptococci  may 
be  cultivated  from  all  the  viscera  and  the  blood  or  demonstrated  micro- 
scopically. After  intravenous  injections  metastatic  foci  of  suppuration 
develop  in  many  joints,  more  rarely  in  the  viscera.  Osteomyelitis  de- 
velops in  young  animals  after  the  use  of  attenuated  cultures  (Lanne- 
longue.  Lexer). 

Guinea  pigs  are  less  susceptible  than  rabbits.  Sheep,  asses,  and  horses 
react  to  streptococcic  infections.  Spontaneous  infections  occur  in  these 
animals. 

Little  is  known  of  the  toxins  produced  by  streptococci.  In  experi- 
mental work  the  secretion  products  of  streptococci,  as  well  as  their  pro- 
toplasmic toxins,  are  active  only  when  used  in  large  amounts  (von 
Lingelsheim,  Aronson).  The  formation  of  toxins  is  favored  when  suit- 
able culture  media  are  used  (according  to  Marmorek,  bouillon  M-ith  the 
addition  of  leucin  and  glycocoll).  ["  G.  F.  Ruediger  has  shown  that 
virulent  streptococci  produce  a  ha'molytic  toxin,  when  grown  in  various 
heated  serums,  and  has  proved  that  this  haamolysin  (streptocolysin)  is 
a  true  toxin,  possessing  a  haptophorous  and  toxophorous  structure." — 
Ricketts'  "  Infection,  Immunity,  and  Serum  Therapy,"  p.  353.] 

The  blood  serum  of  an  animal  immunized  against  streptococci  (rab- 
bit, mouse,  ass,  horse)  protects  other  animals  against  infections  which 
ordinarily  prove  fatal  (Roger,  Knorr,  Marmorek,  von  Lingelsheim,  and 
others).  Streptoeoeci  fj-om  animals  are  not  pathogenic  (active)  for 
man,  and  it  is  (|U('stionable  whether  imnnnie  sera  from  animals,  even  if 
the  streptococci  are  taken  from  man,  will  be  active.  In  the  experiments 
of  Koch  and  Petruschky  prophylactic  injections  did   not  prevent  the 


THE   MOST   IMPORTANT   PYOGENIC   BACTERIA  177 

development  of  erysipelas.  The  Tav(>l  sennii  is  taken  from  a  horse  which 
has  been  inoculated  with  forty-three  strains  of  streptoeoeei  whieh  were 
taken  from  man  only  and  not  passed  through  other  animals.  Favoi-able 
action  is  to  be  expected  in  general  infections  only  when  the  serum  is  used 
in  the  beginning' ;  in  severe  and  old  infections  the  endotoxin  liberated  by 
bacteriolysis  causes  a  dangerous  aggravation  of  the  symptoms. 

The  blood  serum  of  immunized  animals  possesses  also  agglutinating 
properties  which  are  most  active  against  those  cocci  with  the  cultures 
of  which  the  animal  has  been  inununized.  Antilysins  which  neutralize 
the  hiemolysins  are  likewise  present  in  innnune  serum. 

Literature. — Hand  and  Textbooks. — Fliigge.  Die  Mikroorganismen  (Frosch  and 
Kruse).  Leipzig,  Vogel,  1896. — C.  Frcinkel.  Bakterienkiimle.  Berlin,  Hirschwakl. — 
Giinther.  Bakteriologie.  Leipzig,  Thieme,  1902. — Heim.  Bakteriologie.  Stuttgart, 
Enke,  1898. — Kolle  und  Wassermann.  Handb.  d.  pathogenen  Mikroorganismen. 
Jena,  1903-4. — Beitzke.  Ueber  Agglutination  der  Staphylokokken  chirch  inenschliche 
Sera.  Verhandl.  d.  pathol.  Gesellsch.,  September,  1904.  Zentralbl.  f.  allg.  Pathol.,  lid. 
15,  Ergjinzungsheft,  p.  154. — Bruck,  Michaelis  und  SrliuUze.  Beitriige  zur  Serodiagnos- 
tik  der  Staphylokokkenerkrankungen  beim  Menschen.  Zeitschr.  f.  Hygiene  u.  Infek- 
tionskrankheiten,  Bd.  50,  1905,  p.  144. — Fehleiscn.  Zur  Aetiologie  ck>r  Eiterung. 
Arch.  f.  klin.  Chir.,  Bd.  36,  1887,  p.  966. — E.  Frcinkel.  Ueber  menschenpathogene 
Streptokokken.  Miinchner  med.  Woch.,  1905,  p.  1868. — Frnhner  u.  Kiirnbach.  Ein 
Beitrag  zur  primaren  infekt.  Osteomyelitis  des  Pferdes.  Monatsh.  f.  prakt.  Tierheil- 
kunde,  Bd.  14,  1903,  p.  433. — Fromme.  Ueber  prophyl.  u.  therap.  Anwendung  des 
Antistrept.  Serums.  Mi'mch.  med.  Wochenschr.,  1906,  p.  20. — Hentschel.  Pyiimie 
und  Sepsis.  Festschr.  f.  Benno  Schmitt.  Leipzig,  IH9().— J (icobitz.  Ein  Fall  von 
Sepsis,  hervorgerufen  durch  Staphylococcus  citreus.  Miinchner  med.  Woch.,  1905, 
p.  2020. —  Kerner.  Exp.  Beitrag  zur  Hamolyse  und  zur  Agglutination  d.  Strei)t(> 
kokken.  Zentralbl.  f.  Bakteriol.,  Bd.  38,  Orig.,  1905,  p.  223.— Koch  und  F\Hru.sclik)j. 
Beobachtungen  iiber  Erysipelimpfungen  am  Menschen.  Zeitschr.  f.  Hygiene,  Bd.  23, 
1896,  p.  477.— Kolle  und  Otto.  Die  Differenzierung  der  Staphylokokken  mittelst 
Agglutination.  Ibid.,  Bd.  41,  1902,  p.  369. — Lunnelongue  et  Achard.  Etude  exp.  des 
Osteomyelites  a  staph,  et  a,  strept.  Annates  de  I'lnst.  Pasteur,  1891,  No.  4,  p.  209. — 
Lexer.  Experimente  iiber  Osteomyelitis.  Arch.  f.  klin.  Chir.,  Bd.  53,  1897,  p.  266; 
— Die  Schleimhaut  des  Rachens  als  Eingangsi)forte  pyogener  Infektionon.  Il)id., 
Bd.  54,  1897,  p.  736. — v.  Lirtgelsheini.  Streptokokken.  In  Kolle-Wassermanns  Ilandl). 
d.  pathog.  Mikroorg.,  Bd.  3,   1903,  p.  302;— Strcptokokkenimnumitiit.      Ibid.,   lid.  4, 

1904,  p.  1180. — Luharsch.  Streptokokken  als  Krankhcitserregor.  Ergebn.  d.  allgcin. 
Pathol.  V.  Lubarsch  und  Ostertag,  January  3,  1890. — Marmorck.  Die  Arteiidieit 
der  fiir  den  Menschen  pathogenen  Streptokokken.  Berl.  klin.  Wochenschr.,  1902, 
p.  299;— Das  Streptokokkengift.  Ibid.,  p.  253.— Fritz  Meyer.  Die  klin.  Anwendung 
des  Strept.-Serums.  Zentralbl.  f.  Bakt.,  Bd.  36,  Refer.,  1905,  p.  309.— .Uj7/<t.  Die 
Mikroorganismen  der  Mundhohle.  Leipzig,  1892. — v.  Mikulicz.  Die  neuesten  Bestre- 
bungen  der  aseptischen  Wundbehandl.  Chir.-Kongr.  Verhandl.,  1898.  II,  j).  1.— 
Natvig.     Bakt.   Verh/iltnisse   in   weibl.   Genitalsekroten.     Arch.   f.   C.ynakol..    B<1.    76, 

1905,  p.  701. — Neisser  und  Lipstein.  Die  Staphylokokken.  In  Kollo-Wa-sscrmaiins 
Handb.  d.  pathog.  Mikroorg.,  Bd.  3,  1903,  p.  105.— .Vei.s.srr.  Staphylokokkenimmuni- 
tat.  Ibid.,  Bd.  4,  1904,  p.  1150. — Neisser  and  Wechsberg.  Ueber  das  Staphyh)toxin. 
Zeitschr.  f.  Hygiene,  Bd.  36,  1901,  p.  2d9.—Passet.  Untersuchungen  iiber  die  Aetiologie 
der  eitrigen  Phlegmone  des  Menschen.     Berlin,   1885. — Petruschky.     Untersuchungen 


i: 


WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 


iiber  Iiifektion  mit  pyogenen  Kokken.  Zeitschr.  f.  Hygiene,  Bd.  17,  1894,  p.  59; — 
Entscheiduiigsversuche  zur  Frage  der  Spezifitiit  der  Erysipelstrcptokokken.  Ebenda, 
Bd.  23,  1896,  p.  142; — Ueber  die  Konservierung  virulenter  Streptokokkenkulturen. 
Zentralbl.  f.  Bakteriolog.,  Bd.  17,  1895,  p.  560. — Proscher.  Die  Gewinnung  von 
Antistaphylokokkenserum.  Ibid.,  Bd.  37,  Orig.  1904,  p.  295. — Rodet.  De  la  nature 
d'osteomyelite  infectieuse.  Comptes  rendus  de  I'academie  des  sciences,  1884. — Rosens- 
bach.  Mikroorganismen  bei  den  Wundinfektionskrankheiten  des  Menschen.  Wies- 
baden, 1884. — Schottmuller.  Die  Artunterscheidung  der  fiir  den  Menschen  pathogenen 
Streptokokken  durch  Blutagar.  Miinchn.  nied.  Woch.,  1903,  p.  849. — Tavel.  Ex- 
perim.  u.  Klin,  iiber  das  polyvalente  Antistreptokokkenseruni.  Deutsche  iiied.  Wochen- 
schr.,  1903,  p.  950. 


(c)    DIPLOCOCCUS   PNEUMONIA 

The  diplococcus  pneumonia^  diplococcus  or  streptococcus  lanceolatus, 
pneiimococcus  was  demonstrated  by  A.  Fraenkel  in  1886  to  be  the  cause 
of  croupous  pneumonia  in  man,  and  his  findings  were  later  confirmed  by 
Weichselbaum.  The  same  micro-organism  had  been  found  in  rabbits 
dying  of  a  general  fatal  infection  (so-called  sputum-septica'mia)  fol- 
lowing the  injection  of  human  saliva  by  Pasteur  in  1881,  and  had  been 
found  by  Rosenbach  in  1884  and  described  as  the  micrococcus  pyogenes 
tenuis.  Gradually  it  has  been  recognized  that  the  pneumococcus  may  be 
the  cause  of  different  inflammations  following  or  occurring  independent 
of  pneumonia. 

The  separate  halves  of  the  diplococcus  are  shaped  like  a  lancet  or 
candle  flame.     The  pneiunococcus  is  not  motile.     It  possesses  a  capsule 

which   is  constantly   present  when 
the  bacteria  are  found  in  the  tis- 
<Vv  sues,  in  the  blood  of  man  and  ani- 

mals, and  which  may  be  present 
when  the  pneumococcus  is  grown 
on  certain  culture  media  (milk  and 
serum).  The  capsule  appears  pale 
when  the  ordinary  stains  are  em- 
ployed (aniline  stains  and  Gram's 
method)    (Fig.  91). 

It  may  be  cultivated  most  easily 
upon  slightly  alkaline  culture  me- 
dia  at   high   temperatures.      Upon 
agar  and  blood  serum  the  cultures 
Ik:,  ni.  appear  as  small  transparent  drops 

resembling  closely  streptococcic 
colonies.  Gelatin  which  is  not  liquefied  is  less  .suited  for  a  culture 
medium  (at  22°  to  24°  C).  Bouillon  is  somewhat  clouded  in  the  first 
few  days. 


THE   MOST   IMPORTANT   PYOGENIC   BACTERIA  170 

PiKHimococci  die  r;i|)i(lly  upon  all  culliii-c  media,  and  imist  therefore 
be  transplanted  daily.  When  tiansplanted  they  may  nnderjio  a  number 
of  ehanges;  sometimes  the  individual  i)neum(>eoeei  become  more  round, 
sometimes  more  oval,  the  capsule  may  be  Avantin<i-,  and  frequently  they 
form  long-  chains.  All  transitions  to  the  form  of  the  streptococcus  pyo- 
genes may  be  obtained  by  grt)wth  upon  culture  media  (Kruse  and  Pan- 
sini),  yet  the  original  type  may  be  obtained  if  they  are  pa.ssed  throuudi 
animals  a  number  of  times.  ["  Recently  the  danger  of  confusing  the 
pneumococcus  with  the  streptococcus  has  received  renewed  attention,  and 
newer  methods  of  differentiation  render  it  extremely  probal'le  that  such 
confusion  has  occurred  in  the  past.  An  important  dilTerential  method  is 
that  of  cultivation  on  agar  plates  which  contain  blood  (Schottnnieller)  ; 
the  streptococcus  produces  a  clear  zone  of  ha^molyzed  corpuscles  about 
its  colonies,  whereas  the  colonies  of  pneumococcus  present  a  greenish 
color  and  produce  no  haemolysis." — Ricketts'  "  Infection,  Innnunity.  and 
Serum  Therapy,"  p.  338.] 

Pneumococci  remain  viable  and  virulent  for  a  long  time  in  the  dried 
expectoration  of  pneumonia  patients. 

Pneumococci  occur  most  fre(|uently  in  fibrinous  pneuuHMiia,  of  which, 
according  to  Weichselbaum,  they  are  the  cause  in  seventy-one  per  cent 
of  the  cases,  and  in  catarrhal  broncho-pneumonia.  Pleurisy,  peritonitis, 
endopericarditis,  arthritis,  osteomyelitis,  suppuration  in  soft  tissues,  and 
viscera,  and  the  puerperal  uterus  may  occur  secondary  to  pneumo- 
coccic  infection  of  the  lungs.  Infection  in  these  cases  occurs  through 
the  blood,  except  Avhere  pleurisy  or  peritonitis  develops  as  the  result  of 
direct  extension.  Infections  may  occur  independently  of  any  inrianmia- 
tion  of  the  lung,  as  pneumococci  occasionally  gain  access  to  wounds  and 
cause  severe  inflammations  (e.  g.,  mastitis,  Green)  or  phlegmons  which 
may  end  in  general  infection,  with  or  without  metastatic  suppui-atitm. 
Frequently  they  extend  from  the  buccal  and  nasal  cavities,  in  which 
they  are  found  in  an  attenuated  condition  in  healthy  individuals  (Sana- 
relli,  Weichselbaum),  and  produce  suppuration  of  the  accessory  sinuses 
(frontal  and  maxillary  sinuses),  otitis  media,  and  parotitis.  Pneumo- 
cocci, carried  by  the  saliva  or  food  into  the  stomach,  may  cause  peritonitis 
if  the  mucous  membrane  is  ulcerated  or  inflamed  (\Veichsel])aum,  de 
Quervain).  Ha^matogenous  infection  of  the  iieritoneum  after  ]uieumonia 
is  rare  (Jensen). 

That  the  virulence  of  pneumococci  changes  easily  is  indicated  by  the 
different  forms  of  inflannnation  (serous,  flbrinous,  and  suppui-ative^ 
which  it  causes.  In  animal  experiments  it  is  not  difficult  to  demon- 
strate that  pneumococci  from  different  sources  differ  in  virulence,  and 
the  important  fact  that  in  the  course  of  pneumonia  the  cocci  become 
attenuated  as  the  crisis  approaches. 
13 


ISO  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

Rabbits  and  mice,  the  most  susceptible  animals,  die  al'tcr  subeiitaneous 
injections  of  small  amounts  oi*  ^jneiimoeoccic  sputum  or  cultures  in  from 
one  to  two  days  of  a  general  infection  without  local  or  metastatic  sup- 
puration. Pneumocoeci  are  then  found  in  large  numbers  in  the  blood, 
serous  cavities,  viscera,  spleen  and  bone  marrow.  The  more  attenu- 
ated the  pneumocoeci  injected,  the  more  frequently  local  inflammation, 
suppuration,  even  erysipelas  (Neufeld),  and  metastatic  foci  (pneumonic 
infiltration,  suppuration  in  joints)  develop  and  the  longer  the  animals 
remain  alive.  Nothing  definite  is  known  concerning  the  formation  of 
toxins;  apparently  an  endotoxin  is  produced. 

The  blood  serum  of  patients  convalescing  from  pneumonia  contains, 
according  to  F.  and  G.  Klemperer,  Huber,  and  Blumenthal,  specific 
bactericidal  bodies  which  are  formed,  according  to  A.  Wassermann, 
mostly  in  bone  marrow.  Blood  serum  from  convalescents  also  aggluti- 
nates pneumocoeci.  The  blood  serum  of  horses,  immunized  against  pneu- 
mocoeci, prevents  and  cures  infections  in  other  animals  (Mennes  and 
others).     The  antipneumococcic  serum  is  of  no  practical  importance  as 

yet. 

Literature. — A.  Frdnkel.  Ueber  Pneumokokkenbefunde  im  Blute  bei  der  menschl. 
Lungenentziindung.  Internat.  Beitr.  z.  inn.  Med.,  II,  1902. — Green.  The  bacteriology 
of  mastoiditis.  Zentralbl.  f.  Bakteriol.,  Bd.  30,  1901,  p.  468. — HentscM.  Beitrag 
zur  Lehre  von  der  Pyamie  u.  Sepsis.  Festschr.  f.  Benno  Schmitt,  Leipzig,  1896. — Hiiber 
und  Blumenthal.  Ueber  die  antitoxische  u.  therap.  Wirkung  des  menschl.  Blutes 
nach  iiberstandenen  Infektionskrankheiten.  Berlin,  klin.  Wochenschr.,  1897,  p.  671. — 
Jensen.  Ueber  Pneumokokkenperitonitis.  Arch.  f.  klin.  Chir.,  Bd.  70,  1903,  p.  91. — 
G.  und  F.  Klemperer.  Versuche  iiber  Immunisierung  und  Heilung  bei  der  Pneumo- 
kokkeninfektion.  Berl.  klin.  Wochenschr.,  1891,  p.  833. — v.  Leyden.  Pneumonic. 
Die  Deutsche  Klinik,  Bd.  2,  1903.  Serumtherapie,  p.  298. — Menetrier  et  Aubertin. 
Peritonite  a  pneumocoques.  Soc.  med.  des  hopitaux,  Paris,  1901. — Mennes.  Das 
Antipneumokokkenserum  u.  s.  w.  Zeitschr.  f.  Hygiene,  Bd.  25,  1898,  p.  413. — de 
Quervuin.  Zur  Aetiologie  der  Pneumokokkenperitonitis.  Korrespondenzbl.  f.  Schweizer 
Aerzte,  1902. — SamtrelU.  Der  menschl.  Speichel  und  die  Mikroorganismen  der  Mund- 
hohle.  Zentralbl.  f.  Bakteriol.,  Bd.  10,  1891,  p.  d,n.—Schahnd.  Ein  Fall  von  allgc- 
meiner  Pneuinokokkoninfoktion.  Zentralbl.  f.  Bakteriol.,  Bd.  19,  1896,  p.  991.— .1/. 
Wassermann.  PnouinokokkonschutzstofTe.  Deutsche  med.  Wochenschr.,  1899,  p.  141. — 
WeirhseUxmm.  Diplococcus  pneumoniae.  In  KoUe-Wassermanns  Ilandb.  der  pathog. 
Microorg.,  Bd.  3,  p.  189,  1903  mit  Lit. — Ders.  Pneumokokkeiiiinnumitat.  Ibid., 
Bd.  4,  1904,  p.  1164. 

fd)     MICROCOCCUS   TETRAGENUS 

The  micrococcus  tetragenus  was  first  described  by  Koch  (1884)  and 
rJaflfky.  It  may  be  easily  recognized  morphologically,  as  four  cocci 
are  grouped  within  a  capsule.  This  micrococcus  is  found  in  the  pus 
of  tuberculous  lung  cavities,  and  occurs  (luite  fre(|uently  in  human 
sputum  (Biondi,  Sanarelli).  It  is  found  more  rai-ely  in  abscesses  and 
I)h]egmons  of  the  neck. 


THE   MOST    IMPORTANT   I'YOGENIC   BACTElilA 


181 


It  grows  upon  gelatin  (without  liqiu^'action)  and  upon  agar  (form- 
ing white  or  grayish  yellow  eoloniesj,  and  stains  with  aniline  dyes  and 
by    Gram's   method.      AVhite   mice 
and   guinea  pigs  die   after  subcu- 
taneous injections  of  a  general  bac- 
terial infection. 

LiTEKATURE. — SanarclK.  Der  mensrh- 
liche  Speichel  und  die  Mikroorganisineii  iler 
Mundhohle.  Zcntralbl.  fur  Bakteriol.,  lid. 
10,  1891,  p.  817. 


(e)     MICROCOCCUS   GONOR- 
RHCEiE,    GONOCOCCUS 

The  gonococcus  was  first  found 
by  Neisser  (1879)  in  gonorrheal 
pus,  and  cultivated  upon  human 
blood  serum  by  Bumm  (1885).  Its 
specific  relation  to   gonorrhea  was 

demonstrated  by  the  successful   inoculation   of  pure  cultures   into   the 
urethra  of  num. 

It  is  a  diplococcus.     The  broad  and  hilus-like  side  of  the  individual 
cocci,  which  are  of  a  hemispherical,  coffee-bean,  or  reniform  shape,  face 

each  other.  In  pus  the}'  occur  in 
groups,  and  are  either  free  or  inclosed 
within  the  cytoplasm  of  the  cells  lying 
close  to  the  nucleus  (Fig.  93). 

They  stain  with  aniline  dyes  (best 
with  carbolfuchsin  and  methylene  blue) 
and  are  destained  by  Gram's  method. 
They  may  be  cultivated  most  easily 
upon  agar,  the  surface  of  which  has 
been  thickly  covered  with  human  ])l()()d 
(Abel),  or  upon  the  culture  media  (^p<'p- 
tonagar  with  nutrose  and  glycerin  agar) 
recommended  by  A.  AVassermanii.  They 
do  not  grow  upon  the  ordinary  media. 
The  temperature  most  favorable  for  growth  is  about  3(5°  C.;  growth 
ceases  at  temperature  over  38°  C.  The  whitish  gray  colonies  must  be 
I'xamined  carefully  microscopically,  for  there  is  nothing  characteristic 
about  their  macrosco])ic  appearance.  In  making  a  diagnosis,  not  only 
the  form  of  the  cocci,  but  their  growth  upon  special  and  ordinary  cul- 
ture media,  and  the  wa}'  in  which  they  react  the  Gram's  stain,  must  be 
considered. 


'•dt;^* 


182  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

Gonococci  are  so  sensitive  to  drying  that  they  are  killed  after  twenty- 
four  hours;  on  the  other  hand,  they  resist  the  ordinary  agents  used  in 
the  treatment  of  gonorrhea  for  from  five  to  ten  minutes  (Bumm). 

Animals  show  but  little  susceptibility,  their  urethra  and  conjunctiva 
remaining  healthy  after  being  inoculated  with  gonococci.  White  mice 
and  guinea  pigs  either  develop  a  circumscribed  suppurative  peritonitis 
after  artificial  infection  of  their  peritoneum,  or  die  after  twenty-four 
hours  without  any  special  local  inflammation.  The  cocci  die  rapidly  in 
the  animal's  body,  and  so  do  not  produce  general  infections.  They  act 
through  their  toxins,  and  usually  produce  only  a  local  reaction.  The 
joint  infections  produced  by  living  or  dead  cultures  are  benign,  and  the 
suppuration  ceases  spontaneously  (Nicolaysen). 

According  to  A.  Wassermann  and  Nicolaysen,  the  active  toxins  are 
united  with  the  protoplasm,  and  are  only  set  free  when  the  cocci  die. 
De  Christmas  is  the  only  one  who  has  found  a  soluble  toxin  which  is 
developed  in  the  culture  media.  Experimentally,  immunization  against 
the  toxin  is  possible. 

The  field  of  action  of  the  gonococcus  in  man  is  extensive.  Peri- 
urethral abscesses,  epididymitis,  prostatitis,  cystitis,  ureteritis,  pyelone- 
phritis may  develop  secondarily  to  a  gonorrhea  in  man.  The  gonococcus 
plays  even  a  greater  role  in  the  pathology  of  the  female  genital  organs. 
Secondary  to  a  gonorrhea  of  the  urethra  or  cervix,  endoparametritis, 
salpingitis,  oophoritis,  peritonitis,  cystitis,  pyelitis,  and  proctitis  may 
develop.  In  the  newborn  the  gonococcus  may  produce  the  dangerous 
ophthalmia  neonatorum  and  relatively  frequently  the  stomatitis  gonor- 
rhoica. 

All  these  inflammations  are  for  the  greater  part  suppurative  in  char- 
acter. If  the  tendency  to  spread,  as  seen  in  staphylo-  and  streptococcic 
suppuration,  is  absent  and  therefore  the  course  of  the  infection  usually 
benign,  often  enough  they  cause  severe  and  even  fatal  infections.  The 
gonococci  extend  along  mucous  membranes  and  through  lymphatic  chan- 
nels, and  not  infrequently  gain  access  to  blood  vessels.  They  do  not 
always  produce  a  general  infection,  however,  as  they  remain  but  a  short 
time  in  the  blood,  being  deposited,  as  has  been  demonstrated  many  times 
(Pi"oschaska),  in  different  parts  of  the  body,  oven  upon  the  valves  of 
the  heart.  They  have  been  found  in  fatal  endocarditis  and  in  all  possible 
forms  of  metastatic  serous,  serofibrinous,  and  suppiu'ative  inflammation, 
such  as  abscesses  of  soft  tissues,  tendovaginitis.  ])ursitis.  pleuritis,  arthri- 
tis, myoeai'ditis,  once  even  in  pei-icliondritis  (Finger),  in  osteomyelitis 
(Ullmann)  and  pai-otilis  (Coloiiibini).  The  pure  gonoeoecic  metastatic 
inflammation  is  chai-acterized  by  its  benignity,  notwithstanding  its  acute 
febrile  onset.  The  gonococci  soon  die,  Imt  the^  serous  exudation  into 
the  surrounding  tissues,   the   pain,   and   the  contractures  remain  for  a 


THE   MOST   DIPORTAXT   PYOGENIC   BACTERIA  183 

loii.ii-  time.  The  suppurative  peritonitis  with  acute  severe  onset  tends 
to  become  encapsulated  and  may  hcjd  spontaneously. 

The  severe  progressive  intlammations  and  metastatic  processes  are,  as 
a  rule,  caused  by  the  staphylococci  and  streptococci,  as  frequently  the 
gonorrheal  inflannnation  of  the  mucous  membranes  provides  an  infection 
atrium  for  these  bacteria. 

A  previous  gonorrheal  infection  does  not  protect  against  a  later  in- 
fection. 

Literature. — Abel.  Zur  GonokokkenkuUur.  Deutsche  med.  Wochenschr.,  1893, 
p.  265. — E.  Bumm.  Die  gonorrh.  Erkrankungcn  der  weibl.  Harn-  und  Geschlechtsorgane 
Handb.  d.  Gyniik.  von  Veit,  Bd.  1. — de  Christmafi.  Contrib.  a  I'etude  du  Gonocoque 
et  de  sa  toxine.  Annales  de  I'lnst.  Pasteur,  1900,  Xo.  5,  p.  331. — Colombini.  Unter- 
suchungen  iiber  einen  Fall  von  allgem.  gonorrh.  Infektion.  Zentralbl.  f.  Bakteriol.,  Btl. 
24,  1898,  p.  955. — Councilman.  Gonorrhceal  myocarditis.  The  American  Journal  of 
the  ]\Ied.  Sciences,  Bd.  106,  1893. — Finger.  Die  Gonokokkenpyiimie.  Wiener  klin. 
Wochenschr.,  1896. — Finger,  Ghon  und  Schlagenhaufer.  Beitr.  zur  Biologic  des  Gono- 
kokkus.  Arch.  f.  Dermat.  u.  Syphilis,  Bd.  28,  1894,  p.  277; — Endocarditis,  Arthritis, 
Prostatitis.  Ibid.,  Bd.  33,  1895,  p.  141. — v.  Hojmann.  Gonorrhoische  Allgemein- 
infektion  und  Metastasen.  Zentralbl.  f.  Grenzgeb.,  Bd.  6,  1903,  p.  242. — Jncobi  und 
Goldmann.  Tendovaginitis  suppurativa  gonorrhoica.  Beitr.  z.  klin.  Chir.,  Bd.  12, 
1894,  p.  827. — Michaelis.  Ueber  Endocarditis  gonorrh.  und  andere  gon.  Metastasen. 
Internat.  Beitr.  zur  inner.  ]\Ied.,  Bd.  2,  1902. — Xeusser  und  Scholtz.  Gonorrhoe.  In 
Kolle-Wassermanns  Handb.  der  path.  Mikroorganismen,  Bd.  3,  1903,  p.  148. — Xicolay- 
sen.  Zur  Pathogenitat  und  Giftigkeit  des  Gonokokkus.  Zentralbl.  f.  Bakteriol.,  Bd.  22, 
1897,  p.  305. — Proschaska.  Ueber  die  gonorrh.  AUgemein  infektionen.  Virch.  Arch., 
Bd.  164,  1901,  p.  494. — Scholtz.  Immunitat  bei  Gonorrhoe.  In  Kolle-Wassermanns 
Handb.  d.  pathog.  Mikroorg.,  Bd.  4,  1904,  p.  110. — Ullmann.  Osteomyelitis  gonorrh. 
Wien.  med.  Presse,  1900,  No.  49; — Ueber  Allgemeininfekt  ion  nach  Gonorrhoe.  Deufsch. 
Arch.  f.  klin.  Med.,  Bd.  69,  1901,  p.  309.— Unger.  Gonokokken  im  Blute  bei  gon. 
Polyarthritis.  Deutsche  med.  Wochenschr.,  1901,  p.  894. — .4.  ]Va.<i.'^cnnann.  Ueber 
GonokokkenkuUur  und  Gonokokkengift.  Berl.  klin.  Wochensclir.,  1S97,  j).  (iS5: — 
Ein  durch  Gelingen  der  Reinkultur  bewieseuer  Fall  vou  Endocarditis  gonorrh.  Miinch. 
med.  Wochenschr.,  1901,  p.  298 

(f)     BACILLUS   PYOCYANEUS 

Not  infrequently  dressings  saturated  with  wound  secretion  have  a 
greenish  or  bluish  color  and  a  characteristic  sweetish  odor.  The  bacteria 
causing  this  color  and  odor  were  discovered  by  Luecke  in  1802 ;  pure 
cultures  were  first  obtained  by  Gessard  in  1882.  They  have  been  called 
the  bacilli  of  green  or  blue  pus;  the  pus  itself,  however,  is  not  colored, 
but  the  dressings,  the  clothes,  and  the  skin  surrounding  the  wound  as- 
sume the  greenish  or  bluish  color  when  moistened  with  secretion.  The 
deeper  layers  of  large  dressings  have  a  yellowish  or  brown  coloi-.  as  in- 
sut^cient  amounts  of  air  reach  the  secretion  to  give  rise  to  the  blue  color. 

The  bacillus  is  a  small,  actively  motile  rod  which  does  not  form 
spores.    It  stains  with  aniline  dyes,  and  is  destained  by  Gram's  method. 


184  WOUND  INFECTIONS  PRODUCED  BY   BACTERIA 

They  form  wliitish  colonies  and  deposits  npon  solid  culture  media, 
which  soon  assume  a  deep  bluish  green  color  and  develop  a  peculiar 
odor.  Bouillon  cultures  also  assume  this  color  and  odor.  Gelatin  is 
liquefied. 

The  color  of  the  cultures  is  produced  by  two  coloring  matters  which 
develop  throughout  the  culture  when  the  bacilli  are  not  altered  by 
growth  upon  poor  culture  media,  and  when  the  culture  medium  is  suit- 
able and  there  is  free  access  of  air.  Old  cultures  upon  poor  media  lose 
their  ability  to  produce  these  coloring  matters.  Vigorous  bacilli  cannot 
form  these  even  upon  good  culture  media,  when  there  is  not  sufficient 
oxygen  and  the  media  do  not  contain  glucose.  When  symbiotic  with  other 
bacteria,  such  as  the  staphylococci  and  streptococci,  no  coloring  matter  is 
produced  (Muehsam  and  Sehinnnelbusch,  Paul  Krause). 

One  of  the  coloring  matters  (pyocyanin)  may  be  extracted  from  cul- 
tures or  dressings  with  chloroform,  and  when  the  chloroform  evaporates 
it  crystallizes  out  in  the  form  of  long  blue  needles.  The  other  coloring 
matter  (pyofluorescin)  is  not  soluble  in  chloroform,  is  green,  and  fluo- 
rescent. It  depends  upon  the  character  of  culture  medium  whether  one 
or  the  other  develops  alone  or  in  excess.  According  to  Gessard  pyo- 
cyanin alone  is  formed  in  pure  peptone  solutions;  pyofluorescin  alone 
in  uncooked  egg  albumen. 

The  bacillus  pyoc.yaneus  is  frequently  found  in  the  human  skin, 
and  may  be  easily  demonstrated  in  areas  (inguinal  fold,  axillary  fossa, 
and  crena  ani)  which  are  well  supplied  with  sweat  glands  (IMuehsam). 
It  may  be  made  to  grow  actively,  as  indicated  by  the  development  of 
the  green  color,  by  the  use  of  moist  warm  compresses.  The  so-called 
green  sweat,  which  stains  the  clothing  of  many  individuals,  is  produced 
by  the  growth  of  the  bacillus  pyocyaneus  (Eberth).  If  the  bacilli  once 
settle*  upon  a  part  of  the  body,  or  their  development  is  favored  by  the 
use  of  warm  compresses  for  a  week,  it  is  impossible  to  remove  all  of  the 
bacteria  before  an  operation,  even  by  the  most  careful  sterilization,  and 
in  a  few  days  the  dressings  will  be  stained  green.  The  presence  of  the 
l)acilli  in  the  skin,  and  their  resistance  to  antiseptic  solution  explain 
satisfactorily  their  fre((uent  occurrence  in  wound  infections.  There  is 
not  much  danger  of  transferring  these  bacilli  by  the  hands  during  oper- 
ations or  change  of  dressings. 

The  bacillus  pyocyaneus  is  almost  never  absent  in  chronic  suppu- 
ration about  a  fistula.  It  occasionally  occurs  as  a  saprophyte  in  the  in- 
testinal contents,  in  the  bladder,  and  urethra. 

Its  presence  in  the  skin  about  sutured  wounds,  or  even  in  the  wound 
itself,  does  not  disturb  to  any  extent  wound  repair,  as  it  usually  causes 
merely  mild  sup])uration  of  stitch  holes  with  souk^  ehwation  of  tempera- 
ture; rarely  necrosis  of  connective  tissue  and  muscles.    Open,  granulating 


THE   MUST    IMruKTANT   PYUdENlC    BACTERIA  185 

wounds  suffer  much  more  from  infection  with  the  l)aeilluS  pyocyaneus. 
Even  in  these  cases  the  bacilli  do  not  pass  into  the  deeper  tissues,  eausin<^ 
suppurative  inilannnation  accompanied  l)y  fever,  but  excite  a  profuse 
Avound  secretion  which  interferes  with  wound  repair  and  forms  a  fil)i-i- 
nous  coating  M'hich  covers  the  granulating  surface  and  retards  the  growth 
of  epithelium  over  it.     Skin  grafting  of  sucli  wounds  is  never  successful. 

Occasionally  in  man  the  bacillus  i)yocyaneus  becomes  both  pathogenic 
and  pyogenic.  Clinical  observations  of  cases  in  which  the  bacillus  is 
pathogenic  are  reported  frequently,  but  only  a  few  of  these  can  be 
accepted  without  reserve.  Green  found  it  alone  in  eight  cases  of  mas- 
titis. Dangerous,  even  fatal,  pyocyaneus  infecti(ms  may  develop  in  nurs- 
ing children  (Kossel,  M.  Wassermann).  It  has  been  found  in  otitis 
media,  meningitis,  enteritis,  and  suppurative  thrombosis  of  the  umljilical 
arteries  with  metastatic  foci  in  the  lungs.  In  many  cases  of  the  latter 
which  were  apparently  epidemic  and  presented  the  clinical  ])ictnre  of 
a  general  infection,  M.  Wassermann  cultivated  a  virulent  pyocyaneus 
bacillus  from  the  different  foci.  The  bacillus  pyocyaneus  has  been  fre- 
quently found  in  the  blood  of  small  children  dying  of  an  enteritis  accom- 
panied by  fever  and  haemorrhages. 

In  animals  (guinea  pigs  and  rabbits)  the  bacillus  produces  a  power- 
ful toxin,  although  it  does  not  multiply  rapidly.  It  produces  no  disturb- 
ance in  wounds,  but  after  subcutaneous  or  intravenous  injection  of  snuill 
amounts  of  a  virulent  culture  a  severe  infection  (with  nephritis  and 
haemorrhages  into  gastrointestinal  mucous  membrane)  develops  which 
proves  fatal  in  twenty-four  hours  or  after  many  weeks.  Death  occurs 
rapidly  after  the  injection  of  larger  doses,  and  bacilli  can  be  demon- 
strated in  the  blood.  Bacilli  are  not  found  in  the  blood,  however,  Avhen 
smaller  doses  are  injected,  and  the  animal  lives  for  some  time,  as  the 
bacilli  are  excreted  by  the  liver  and  kidneys  and  can  be  demonstrated 
in  the  bile  and  urine.  They  appear  in  the  latter  in  a  quarter  of  an 
hour  after  injection  (von  Klecki).  Paralysis  and  degeneration  of  the 
viscera  develop  in  chronic  cases. 

Large  enough  doses  of  sterile  cultures  have  a  similar  action  to  that 
described  above,  as  they  contain  toxins  secreted  by  the  bacilli.  The 
toxins  must  not  be  considered  as  identioal  with  the  coloring  matters. 
In  man  the  injection  of  sterile  cultures  produces  a  general  (mild  fever) 
and  local  (erysipelatous)  reaction  (Schimmelbusch).  The  poisons  are 
partly  toxins  which  are  held  in  solution  in  the  culture  fluids,  and  partly 
endotoxins  which  are  bound  to  the  bacterial  protoplasm.  The  endotoxin 
dissolves  red  blood  corpuscles,  and  therefore  contains  a  h:vmolytic  poison 
or  pyocyanolysin  (Bullock  and  Hunter).  It  is  questionable,  however, 
whether  this  ha^molytic  action  is  not  due  to  the  alkali  content  of  the 
culture  medium  (Jordan). 


186  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

Animals  may  be  artificially  immunized.  A.  Wassermann  has  shown 
that  the  blood  serum  of  animals  immunized  with  the  soluble  toxin  is 
active  against  the  bacilli  and  the  toxin.  The  serum  is  therefore  both 
bactericidal  and  antitoxic.  The  serum  of  animals  immunized  with  living 
cultures  has  only  a  bactericidal  action. 

(g)     BACTERIUM   COLI   COMMUNE 

This  bacillus  was  found  by  Emmerich  (1884)  in  patients  dying  of 
cholera,  and  was  regarded  by  him  as  the  cause  of  the  disease.  Later 
(1885)  it  was  demonstrated  by  von  Escherich  to  be  one  of  the  ordinary 
intestinal  bacteria  of  nursing  children,  and  w^as  apparently  cultivated 
simultaneously  by  Passet  from  the  pus  of  a  periprocteal  abscess  (bacillus 
pyogenes  fa»tidus). 

They  occur  in  the  form  of  short  rods,  singly  or  in  pairs,  among  which 
coceoid  forms  may  be  found ;  are  provided  with  flagella,  and  are  there- 
fore capable  of  motion.  The  bacilli  do  not  form  spores;  are  fairly  re- 
sistant to  high  and  low  temperatures,  but  not  to  drying  (Walliczek)  ; 
stain  with  the  aniline  dyes,  but  are  destained  by  Gram's  method. 

They  form  upon  gelatin  small,  round,  yellowish  white  colonies.  Gela- 
tin is  not  liquefied.  Stab  cultures  resemble  a  nail  with  a  flat  head  as 
the  bacilli  develop  rapidly  upon  the  surface  of  the  gelatin.  The  bacilli 
form  transparent,  grayish  white  deposits  upon  agar,  and  render  bouillon 
very  cloudy.  In  glycerin  and  media  containing  grape  or  milk  sugar 
they  produce  acid  fermentation  and  gas.  The  formation  of  gases  (H 
and  CO2)  may  be  most  easily  demonstrated  in  stab  cultures  in  glucose 
agar,  in  which  numerous  gas  bubbles  develop  in  twenty-four  hours. 

The  formation  of  acids  (lactic,  acetic,  and  formic)  may  be  easily 
demonstrated  by  growth  in  sterile  milk,  w^hich  becomes  curdled  after  a 
few  days.  They  produce  in  sugar  free  but  peptone-containing  media,  to 
which  has  been  added  potassium  nitrite  and  sulphuric  acid,  a  red  color- 
ing substance  (nitroso-indol).  (This  test  may  be  used  to  differentiate  the 
colon  from  other  closely  related  bacteria.) 

The  bacillus  coli  communis  is  a  very  widely  distributed  saprophyte. 
It  plays  an  important  role  in  pathology,  both  as  a  pyogenic  and  putre- 
factive bacterium.  It  inhabits  with  closely  related  species  (the  groups 
of  colon  bacilli)  the  intestine,  especially  tlu^  large  intestine  of  man  and 
many  animals,  but  also  occurs  outside  of  the  body  (e.  g.,  in  water,  air, 
in  the  dust  of  schoolrooms,  upon  the  skin,  in  the  clothing,  etc.).  Its 
presence  in  the  intestinal  contents  ])ec<)ines  of  significance  only  in  patho- 
logical conditions.  In  cholera,  dysentery,  tyi)h()id  fever,  cholera  nos- 
trans,  and  the  connnon  forms  of  entei-itis.  an  ijifectron  atrinm  is  provided 
for  llic  colon  l)iiciHi  which   Irciiucntly  inciv^ase  rapidly  in  numbers  and 


THE   MOST   IMPORTANT   PYOGENIC   BACTERIA  187 

virulence.  As  a  result  of  this  increase  in  virulence  followinfj  lesions  in 
the  intestines,  they  may  produce  peritonitis  after  passing  through  the 
intestinal  wall  or  after  absorption,  metastatic  suppuration,  or  general 
infection.  Infection  atria  are  provided  for  colon  bacilli  by  wounds  of 
the  intestinal  nuicous  membranes,  by  intestinal  perforation  following 
ulcer  or  injury,  by  circulatory  disturbances  and  invaginations  which 
render  the  intestinal  wall  more  permeable  for  bacteria.  Colon  bacilli 
may  cause  circumscribed,  progressive,  or  general  suppurative  peritonitis. 
They  are  frequently  found  in  appendiceal  and  periprocteal  abscesses,  in 
suppurative  cholecystitis  and  cholangitis,  and  in  abscesses  of  the  liver 
following  these  lesions,  and  occur  also  in  general  bacterial  infections  and 
metastatic  foci  (endocarditis,  pleuritis,  meningitis,  arthritis,  periostitis, 
etc.). 

It  is  conceivable  that  in  severe  intestinal  catarrh  the  bacilli  may  l)c 
absorbed  and  pass  into  the  lymphatic  and  blood  vessels  (Seitz).  It  is 
doubtful,  however,  whether  in  all  cases  of  meningitis,  pleuritis,  and 
strumitis  in  which  the  colon  bacillus  is  found  the  infection  occurred  in 
this  way,  as  the  bacilli  are  widely  distributed  in  the  external  world  and 
the  infection  may  have  occurred  from  without.  The  colon  bacillus  has 
been  found  in  felons,  in  lymphangitis  ending  in  suppuration,  often  with 
the  formation  of  gas  (gas  phlegmon),  in  otitis  media,  and  in  a  few  cases 
of  osteomyelitis  in  association  with  other  bacteria.  Recent  operation- 
wounds  infected  with  the  colon  bacillus  are  foul  smelling  and  dry  and 
are  accompanied  by  an  elevation  of  temperature.  The  wound  surfaces 
become  necrotic  and  gangrenous,  and  granulation  tissue  which  secretes 
profusely  is  foimied,  but  slowly  (cf.  Putrefactive  Infections). 

If  the  bacilli  gain  access  to  the  bladder,  this  occurring  most  fre- 
quently in  man  during  catheterization,  severe  infections  (cystitis,  pye- 
litis, pyelonephritis)  which  may  prove  fatal  if  they  become  general  may 
develop.  Sittmann  and  Barlow  in  such  a  case  cultivated  the  bacillus 
coli  communis  from  the  blood  eleven  hours  before  death.  If  the  bacillus 
gains  access  to  the  vagina,  puerperal  infections  may  develop  (Eisenhart). 

The  demonstration  of  colon  bacilli  in  cadavers  is  no  proof  that  they 
had  any  causal  connection  with  death,  for  the  bacilli  pass  through  the 
intestinal  wall  shortly  after  death  and  become  widely  distributed. 

The  mouse,  guinea  pig,  rabbit,  dog,  and  cat  are  best  suited  for  ex- 
perimental purposes.  Abscesses  follow  cutaneous  and  subcutaneous  in- 
jections. After  intraperitoneal  and  intravenous  injections  of  virulent 
cultures,  there  develops  besides  the  suppurative  pei'itouitis  following  in- 
traperitoneal injection  a  fatal  general  infection,  associated  almo.st  always 
with  a  severe  enteritis,  bacteria  occurring  in  the  blood  and  viscera. 
Ackermann  produced  osteomyelitis  in  young  aninuUs  by  intravenous 
injections.     Guyon  produced  a  cystitis  by  intravenous  injections,  having 


188  WOUND   INP^ECTIONS   PRODUCED   BY   BACTERIA 

caused  previously  a  urinary  retention  by  closing  the  urethra.  According 
to  Buchner  the  pyogenic  action  depends  upon  chemotactic  substances  in 
the  protoplasm,  but  the  culture  also  contains  soluble  toxins. 

A  susceptible  animal  may  be  immunized  by  injecting  increasing  doses 
of  living  cultures,  and  the  blood  serum  obtained  from  immunized  animals 
will  agglutinate  the  bacilli  {vide  Typhoid  Bacilli;  cf.  also  Putrid  In- 
fections). 

Literature. — Ackermann.  Les  osteomyelites  exp.  prov.  par  bact.  coli  comm. 
Arch,  de  med.  exp.  T.  7,  1895,  p.  330. — Brunner.  Eine  Beobachtung  v.  Wundinfektion 
durch  d.  Bact.  coli  comm.  Zentralbl.  f.  Bakteriol.,  Bd.  16,  1894,  p.  993. — Cacace.  Die 
Bakterien  d.  Schule.  Zentralbl.  f.  Bakteriol.,  Bd.  30,  1901,  p.  653. — Dmochowski  und 
Janowski.  Zwei  Falle  von  eiteriger  Entziind.  der  Gallengange  durch  Bact.  coli  comm. 
Zentralbl.  f.  allgem.  Pathol.,  Bd.  5,  1894,  p.  277. — Eisenhart.  Puerperale  Infektion  m. 
todl.  Ausgange  durch  Bact.  coli  comm.  Arch.  f.  Gyn.,  Bd.  47,  1894,  p.  189. — Escherich 
u.  Pfaundler.  Bact.  coli  comm.  In  KoUe-Wassermanns  Handb.  der  pathog.  Mikro- 
organismen,  Bd.  2,  1903,  p.  334. — Gibbert.  De  la  colibacillo.se.  Semaine  med.,  1895. — 
Henke.  Beitrag  zur  Verbreitung  des  Bact.  coli  comm.  in  der  Aussenwelt.  Zentralbl. 
f.  Bakteriol.,  Bd.  16,  p.  481,  1894. — Hitschmann  u.  Michel.  Eine  vom  Bact.  coli  comm. 
hervorgerufene  Endokarditis  u.  Pyamie.  Wien.  klin.  Wochenschr.,  1896.— /aito. 
Experim.  Untersuchungen  iiber  die  Agglutination  d.  Typhusbaz.  u.  d.  Mikroorg.  aus  d. 
Koligruppe.  Zeitschr.  f.  Hygiene,  Bd.  33,  1900,  p.  185. — Kiessling.  Das  Bact.  coli 
comm.  Hygien.  Rundschau,  Bd.  3,  1893,  p.  724. — Krogius.  Ueber  den  gewohnl.  bei 
der  Harninfektion  wirksamen  path.  Baz.  (Bact.  coli  comm.).  Zentralbl.  f.  Bakteriol., 
Bd.  16,  1894,  p.  1006. — Oker-Blom.  Beitrag  zur  Kenntnis  des  Eindringens  des  Bact. 
coli  comm.  in  die  Darmwand  in  path.  Zustanden.  Zentralbl.  f.  Bakt.,  Bd.  15,  1894,  p. 
588. — Pfaundler.  Spez.  Immunitatslehre  betr.  Bact.  coli.  In  Kolle-Wassermanns 
Handb.  d.  pathog.  Mikroorg.,  Bd.  4,  1904,  p.  905. — -Seitz.  Darmbakterien  und  Darm- 
bakteriengifte  im  Gehirn.  Korresp.-Bl.  f.  Schweiz.  Aerzte,  1900. — Sittmann  und  Barlow. 
Ueber  einen  Befund  von  Bact.  coli  comm.  im  lebenden  Blut.  Deutsch.  Arch.  f.  klin. 
Med.,  Bd.  52,  1894,  p.  250. — Walliczek.  Resistenz  des  Bact.  coli  comm.  gegen  Ein- 
trocknen.     Zentralbl.  f.  Bakteriol.,  Bd.  15,  1894,  p.  949. 


(h)     BACILLUS   TYPHOSUS 

The  typhoid  bacillus  was  first  seen  and  described  by  Eberth  (1880) 
in  the  viscera  of  patients  dying  of  typhoid  fever;  later  by  Koch.  Pure 
cultures  of  the  bacillus  were  first  obtained  by  GaflPky  (1884). 

The  bacilli  are  short  and  thick  rods  with  rounded  ends  which  do  not 
form  spores.  They  are  provided  with  long,  actively  motile,  wavy  fla- 
gella,  which  are  attached  all  along  the  sides  and  at  ends  of  the  bacilli. 

The  typhoid  bacilli  grow  upon  the  ordinary  media,  best  when  there 
is  free  access  of  air.  Tn  gelatin,  which  is  not  liquefied,  the  superficial 
colonies  are  flat,  with  wavy  margins,  while  tlic  ^[^\'\^  colonies  are  about 
the  size  of  the  head  of  a  ])iii,  i-ouiid  and  grayish  white  in  color.  In  stab 
cultures  white  threads  are  foi-med.  Upon  agar  they  form  a  transparent, 
closely  attaclicd  film.     Bouillon  is  clouded  rapidly. 


THE   MOST   IMPORTANT   PYOGENIC   BACTERIA  189 

The  typhoid  bacilli   have   a   miiiilx'i-  of  eharactcristies  which  cnal}lc 
one  to  dift'erentiate   them  froiu   the   colou   bacillus  and  closely  related 
forms.     They  do  not  form  gas  in  culture  media  containing  glucose,  do 
not    coagulate    milk,    and    produce    no 
color  reaction  (Indol)    {vide  Bacterium 
Coli  Commune).     No  single  test  is  suf- 
ficient to  distinguish  the  typhoid  from 
the  colon  bacillus ;  a  number  must  be 
tried  (see  below,  Pfeiffer,  AYidal). 

In  moist   conditions  the   bacillus 
viable  for  a  long  time,  in  w^ater  sonu 
weeks,    in    fecal    masses    many    montlis 

(Uffelmann,   Karlinski)  ;    on   the   other  \  *^-%l    "v  v 

hand,   it  is  rapidly  destroyed  by  dry-  ^'^  v«*.*- 

ing   (Kruse).  ^^i^S^fS^^li^^ 

Typhoid  bacilli  are  excreted  in  the  ii,,.  u4. 

feces  and  urine;  in  the  latter  even  dur- 
ing convalescence  (Petrusehky).  They  remain  vialile  for  a  long  time 
outside  the  body  in  damp  places  (e.  g.,  the  floor),  so  that  the  danger  of 
infection  is  great.  The  bacilli  may  be  easily  transferred  to  the  mouth 
by  the  infected  fingers  or  in  drinking  water,  during  an  epidemic,  which 
comes  from  wells  adjacent  to  privies  or  outhouses. 

The  intestinal  canal  affords  the  infection  atrium  for  the  typhoid 
bacilli.  They  settle  in  the  lymph  follicles  and  cause  inflammation,  necro- 
sis, and  ulceration.  Nothing  is  known  of  the  symptoms  of  wound  infec- 
tions w'ith  typhoid  bacilli. 

The  bacilli  do  not  remain  confined  to  the  lymph  follicles  in  the  in- 
testinal wall  and  mesenteric  lymph  nodes,  which  are  soon  involved.  They 
early  pass  into  the  blood  stream  and  become  distributed  in  small  foci  in 
all  the  viscera  and  tissues,  and  during  pregnancy  may  even  be  deposited 
in  the  fcetus.  They  remain  only  temporarily  in  the  blood,  occurring  in 
the  greatest  numbers  during  the  eruptive  stage,  and  therefore  there 
may  be  some  difficulty  in  demonstrating  them  in  the  blood,  although 
it  has  frequently  been  done  (Castellani  and  Schottmueller,  Bui-dach.  and 
others).  The  bacilli  are  found  most  abundantly  in  the  spleen,  then  in 
the  bone  marrow  and  periosteum ;  they  have  also  been  demonstrated  in 
the  liver  and  gall  bladder,^  in  the  kidney,  the  rose  s]>ots.  and  in  the  heart 
valves  in  endocarditis.  Groups  of  bacilli  may  remain  in  the  body  for 
a  long  time  without  giving  rise  to  symptoms;  for  example,  Buschke  has 


1  Infection  of  the  mucous  membrane  of  the  gall  bladder  with  typhoid  l^acilli  is  fre- 
quently followed  by  a  chronic  catarrhal  inflammation,  \vhich  is  an  etiological  factor  in 
gall-stone  formation. 


190  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

found  them  in  an  osteal  focus  seven  years  after  typhoid  fever,  Sultan  six 
years  after. 

Occasionally,  but  relatively  infrequently,  they  cause  inflammation 
and  suppuration,  which  occurs  most  freqviently  during  convalescence 
(post-typhoid  inflammation).  If  the  typhoid  bacilli  act  alone  the  in- 
flannnation  usually  pursues  a  mild  and  chronic  course.  The  pus  which 
is  formed  is  thin,  reddish  yellow  in  color,  and  contains  but  few  cells. 

The  pyogenic  action  of  t.yphoid  bacilli  has  been  proven  by  animal 
experimentation,  and  by  finding  them  unassociated  with  other  bacteria  in 
dilferent  forms  of  post-typhoid  suppurative  inflannnation,  such  as  suppu- 
ration of  marrow  of  bone  and  periosteal  foci  with  abscesses  of  soft  tis- 
sues, in  suppuration  of  the  subcutaneous  tissues,  and  of  nuiscle.  in  arthritis 
and  in  suppurative  foci  in  the  viscera,  parotid  gland,  goiter,  eye,  testicle, 
epididymis,  ovary,  spleen,  liver,  in  pleurisy,  meningitis,  and  peritonitis. 

Quite  frequently  post-typhoid  inflammations  pursue  a  severe  clinical 
course.  In  these  cases  pyogenic  cocci  and  other  micro-organisms  (pneu- 
mococci,  colon  bacilli)  are  often  the  cause  of  the  inflammation,  the 
typhoid  infection  in  the  intestine  providing  the  infection  atrium  or  con- 
ditions favorable  for  the  development  of  these  bacteria.  In  these  severe 
cases  the  typhoid  bacilli  have  been  found  with  other  bacteria  or  the 
latter  alone.  It  is  possible,  however,  that  in  these  cases  the  typhoid 
bacilli  nuiy  have  died  in  the  abscesses  or  that  the  infection  with  pyogenic 
cocci  was  secondary. 

The  entire  course  of  the  disease  may  be  influenced  by  a  mixed  infection, 
and  that  a  general  bacterial  infection  with  other  bacteria  may  develop 
has  been  positively  demonstrated  by  finding  these  bacteria  in  the  blood. 

Guinea  pigs  and  mice  are  the  most  susceptible  of  all  the  animals 
used  for  experimental  purposes.  They  die  in  from  one  to  two  days 
after  the  injections  of  small  amounts  of  typhoid  cultures  into  the  peri- 
toneal cavity.  Death  is  due  to  the  action  of  the  toxins,  as  the  bacilli 
are  found  in  the  blood  only  after  the  use  of  much  larger  amounts,  and 
are  then  deposited  in  the  viscera.  After  the  injection  of  slightly  virulent 
cultures  the  animal  lives  for  some  days,  and  only  a  few  bacteria  can  then 
be  found.  The  experimental  production  of  the  disease,  as  it  occurs  in  man, 
by  the  feeding  of  cultures,  has  been  successful  to  only  a  limited  degree. 

The  pyogenic  action  of  the  bacillus  after  injection  into  different  tis- 
sues, joints,  and  body  cavities  of  rabbits  and  dogs  has  been  positively 
demonstrated   (Orloff,  Dmochowski  and  Janowski,  Kruse). 

The  virulence  of  typhoid  bacilli  decreases  upon  culture  media,  but 
may  be  raised  by  passing  them  through  animals. 

The  toxins  arc  pai-tly  present  in  the  culture  media  and  ])ai'tly  freed 
by  the  death  of  the  bacteria,  both  the  culture  filtrate  freed  of  bacteria 
and  the  bacilli  kilh'd  with  chloi-ofoi-m   vajior  l)cing  active.     The  toxins 


THE   MOST    IMPORTANT    PYOGENIC    BACTI:RIA  191 

have  a  special  action  upon  the  intestinal  mucous  membrane  (Sanarelli). 
In  man  sterile  cultures  injected  in  small  amounts  produce  a  rapid  but 
transitory  reaction  (R.  Pfeiffer  and  Kolle).  According'  to  E.  and  P. 
Levy  the  culture  filtrate  contains  a  ha^molytic  substance,  as  it  dissolves 
red  blood  corpuscles. 

A  susceptible  animal  may  be  imnumized  by  one  injection  of  a  culture 
in  which  the  bacilli  have  been  killed  (Briefer,  Kitasato,  and  A.  AVasser- 
mann). 

According  to  R.  Pfeiffer,  the  blood  scrum  of  an  inumuiized  animal 
is  not  antitoxic,  but  bactericidal.  It  kills  and  dissolves  typhoid  bacilli 
in  a  short  time,  but  does  not  neutralize  the  toxins;  the  serum  should 
therefore  be  used  only  as  a  prophylactic  measure.  The  blood  serum  of 
convalescent  patients  and  individuals  Avho  have  been  inoculated  with 
small  amounts  of  a  sterile  culture  have  this  bactericidal  property 
(Pfeiffer  and  Kolle).  The  lymph  nodes,  spleen,  bone  marrow,  and 
thymus  gland  must  be  regarded  as  the  principal  sources  of  typhoid 
antibodies  (Wassermaun).  Protective  inoculation  of  soldiers  with  dead 
cultures  has  been  performed  with  favorable  results  ((Jaffky  and  Kolle). 

In  order  to  lessen  the  unpleasant  symptoms  following  inoculation, 
which  are  apparently  due  to  the  decomposition  products  of  the  bacteria 
and  the  culture  media,  Bassenge  and  j\Iayer  prepared  a  filtrate  from 
typhoid  cultures  which  was  freed  of  the  decomposition  products  by  shak- 
ing in  sterile  water. 

According  to  Pfeift'er,  the  specific  bactericidal  properties  of  tlie  serum 
of  artificially  immunized  animals  maj^  be  used  to  establish  the  identity 
of  questionable  typhoid  bacilli.  In  this  test  the  bacilli  in  question 
should  be  injected  into  the  peritoneal  cavity  of  an  immunized  guinea 
pig.  If  the  animal  remains  alive  the  bacilli  injected  are  typhoid,  as  the 
bacilli  are  killed  by  the  serum.  The  solution  of  the  bacteria  may  be 
followed  under  the  microscope  if  some  of  the  peritoneal  fluid  is  with- 
drawn with  a  capillary  tube,  and  a  hanging  di-op  ]ii'epared.  This  reac- 
tion is  specific  if  the  animal  is  immunized  against  typhoid,  and  therefore 
can  be  used  to  establish  the  identity  of  the  typhoid  bacillus. 

In  vitro  the  typhoid  immune  serum,  which  within  the  body  kills  and 
dissolves  typhoid  bacilli,  has  another  action.  When  a  suspension  of  the  ba- 
cilli are  mixed  with  the  serum  upon  a  slide  or  in  a  small  tube,  they  rapidly 
lose  their  motility  and  become  agglutinated.  This  reaction  depends  upon 
substances  which,  because  of  their  action,  have  been  called  specific  agglu- 
tinins. The  blood  serum  of  many  typhoid  patients  early  shows  this  spe- 
cific agglutinating  property  (Widal  and  Gruber),  and  this  has  been  made 
use  of  in  making  a  diagnosis  of  ty])hoid  fever  in  the  Widal  or  sero-diag- 
nostic  test.  A  negative  result  does  not,  however,  exclude  typhoid,  for 
this  agglutinating  property  of  serum  develops  late  in  many  cases. 


192  WOUND    INFECTIONS   PRODUCED   BY   BACTERIA 

Literature. — Bassenge  und  Mayer.  Zur  Schutzimpfung  gegen  Typhus.  Deutsche 
med.  Wochenschr.,  1905,  p.  697.~Brieger,  Kitasato  und  W assermann.  Ueber  Im- 
munitat  und  Giftfestigung.  Zeitschr.  f.  Hygiene,  Bd.  12,  1892,  jd.  254. — Burdach.  Der 
Nachweis  v.  Typhusbaz.  a.  Menschen.  Zeitschr.  f.  Hygiene,  Bd.  41,  1902.— Dmochowski 
u.  Janowski.  Experim.  Untersuchungen  iiber  Mischinfektion  bei  Typhus  u.  ijber 
Eiterung  bei  Tyi^hus.  Beitr.  z.  path.  Anat.  Ziegler,  Bd.  17,  1895,  p.  221.— Eberth. 
Die  Organismen  in  den  Organen  bei  Typhus  abdom.  Virchows  Archiv,  Bd.  81,  1880, 
p.  58; — Neue  Untersuchungen  iiber  den  Baz.  des  Abd.-Typh.  Virchows  Arch., 
Bd.  83,  1881,  p.  486; — Der  Typhusbazillus  u.  die  intestinale  Infektion.  v.  Volkmanns 
Samml.  klin.  Vortrage,  No.  226,  1883. — Gaffky.  Aetiologie  des  Abdominaltyphus. 
Mitt,  aus  dem  Gesundheitsamte,  Berlin,  1884. — Gaffky  und  Kollc.  Ueber  Typhus- 
schutzimpfungen.  Khn.  Jahrb.,  Bd.  14,  1905. — Lcntz.  Imniunitat  bei  Typhus.  In 
Kolle-Wassernianns  Handb.  d.  pathog.  Mikroorg.,  Bd.  4,  1904,  p.  894. — E.  und  P. 
Levy.  Ueber  das  Hamolysin  des  Ty^jhusbaziUus.  Zentralbl.  f.  Bakteriol.,  Bd.  .30, 
1901,  p.  405. — Neufeld.  Typhus.  In  Kolle-Wassermanns  Handb.  d.  pathog.  Mikro- 
organismen,  Bd.  2,  1903,  p.  204. — R.  Pfeiffer  und  Kolle.  Spezif.  Immunitatsreaktion 
des  Typhusbazillus.  Zeitschr.  f.  Hygiene,  Bd.  21,  1896,  p.  203;— Experim.  Unter- 
suchungen zur  Frage  der  Schutzimpfung  des  Menschen  gegen  Tyjahus  abd.  Deutsche 
med.  Wochenschr.,  1896,  p.  735.— Sanarelli.  Die  Gifttheorie  d.  Abdominaltyphus. 
Zentralbl.  f.  Bakteriol.,  Bd.  16,  1894,  p.  188. — A.  Wassermann.  Weitere  Mitt,  iiber 
Seitenkettenimmunitat  (Lymphdr.,  Knochenmark,  Milz,  Thymus  als  Bildungsstatten 
der  Schutzstoffe).  Berl.  klin.  Wochenschr.,  1898,  p.  209.— Widal  et  Sigard.  Etude 
sur  le  Serodiagnostic  et  sur  la  Reaction  agglutinante  chez  les  typhiques.  Annales  de 
rinst.  Pasteur,  T.  11,  1897,  p.  353. 

OTHER   BACTERIA   OCCASIONALLY   PRODUCING   PUS 

Besides  the  above  described  pyogenic  bacteria,  there  are  a  number  of 
other  bacteria  (influenza,  pneumonia  bacilli)  which  occasionally  produce 
suppurative  inflammation.  These  will  be  mentioned  when  the  suppura- 
tive inflammations  of  the  difl^erent  tissues  are  described. 

The  pyogenic  action  of  the  bacillus  of  tuberculosis,  glanders,  and  of 
the  aetinomyces  will  be  discussed  in  Part  II,  Chapter  III,  dealing  with 
these  diseases. 


CHAPTER    II 

THE   INFECTION    ATRIA    OF   PYOGENIC    BACTERIA 

A  WOUND  of  the  skin  or  mucous  membrane  affords  most  frequently 
the  infection  jiliiiitn  for  pyogenic  bacteria.  It  is  incorrect,  however,  to 
regard  a  woiitid  as  the  only  infection  atrium,  and  to  suppose  that  one 
exists  in  each  inlVction.  Pyogenic  and  other  bactei'ia  may  under  cer- 
tain conditions  pass  through  intact  skin  and  niucous.membrane  and  pene- 
trate granulation  tissue. 


THE    INFECTION   ATRIA   OF    PYCKJKXIC    BACTERIA  1H8 

Schimmelbusch 's  experiments  in  the  production  of  furuncles  demon- 
strate how  bacteria  may  enter  intact  skin.  The  presence  of  the  staphy- 
lococci upon  the  surface  of  the  skin  alone  is  not  sufficient  to  produce 
an  inflammation.  A  second  factor  is  required,  for  the  cocci  must  be 
mechanically  rubbed  or  forced  into  roughened  areas  or  fissures  of  the 
skin  or  into  the  points  of  exit  of  hairs  or  lanugo  hair,  much  less  fre- 
quently into  the  ducts  of  sweat  glands.  After  the  cocci  have  been 
rubbed  into  intact  skin  they  may  be  demonstrated  about  the  hair  shaft. 
They  multiply  and  pass  into  the  hair  follicle,  and  there  produce  the 
inflammation.  From  such  a  focus  the  cocci  may  pass  into  lymphatic 
vessels  and  nodes  or  invade  the  blood  vessels,  as  the  development  of 
suppurative  osteomyelitis  in  some  distant  parts  following  a  furuncle 
demonstrates. 

Similar  experiments  with  a  number  of  pyogenic  and  other  bacteria, 
such  as  anthrax  (Wasmuth)  and  tubercle  bacilli  (Cornet)  have  been 
made.  All  these  experiments  show  conclusively  that  bacteria  may  be 
rubbed  into  the  hair  follicle,  the  skin  being  intact,  and  that  in  this  way 
severe,  or  even  fatal  infection  (animal  experiments  with  anthrax)  may 
be  produced. 

An  intact  mucous  membrane  may  be  penetrated  by  bacteria  (espe- 
cially by  streptococci,  pneumococei,  less  frequently  by  staphylococci, 
colon  bacilli,  etc).  Only  very  virulpnt  bacteria  are  able  to  do  this,  as 
experimental  work  upon  the  mucous  membrane  of  the  mouth  cavity, 
pharynx,  and  intestines  (Lexer,  Bail)  has  shown.  The  bacteria  pass 
into  and  multiply  in  the  spaces  produced  by  the  continual  and  active 
juigration  of  leucocytes  through  the  epithelium  (Stohr's  epithelial 
spaces)  covering  the  lymphatic  follicles  (over  tonsillar  crypts,  lingual, 
and  pharyngeal  tonsil,  and  Peyer's  patches).  The  bacteria  must,  how- 
ever, be  highly  virulent  before  they  can  invade  the  tissues,  as  the  wan- 
dering leucocytes  have  bactericidal  properties  (vide  p.  157). 

Less  virulent  bacteria,  as  a  rule,  cause  but  little  damage  while  they 
remain  upon  the  mucous  membranes,  as  they  are  prevented  from  pene- 
trating them  by  the  secretion  of  the  cells  and  the  movement  of  the  cilia. 
The  constant  presence  of  pathogenic  bacteria  upon  the  mucous  membranes 
of  the  nasal,  buccal,  and  pharyngeal  cavities,  of  the  respiratory  passages 
and  gastrointestinal  tract,  and  the  negative  results  of  animal  experi- 
ments (Buchbinder  and  others),  Avhich  have  shown  that  bacteria  of 
ordinary  virulence  do  not  penetrate  normal  mucous  membrane,  dem- 
onstrate that  this  is  so.  If,  however,  the  mucous  membranes  are  injured 
(e.  g.,  if  the  protective  mechanism  is  interfered  with)  the  harmless  bac- 
teria will  become  virulent,  will  multiply  rapidly,  penetrate  the  mucous 
membranes,  and  produce  inflammation  of  the  deeper  tissues.  The  pro- 
tective action  of  the  mucous  membranes  may  be  interfered  with  in  a 


194 


WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 


number  of  ways:  for  example,  by  destruction  or  paralysis  of  the  cilia 
(trachea  and  bronchi),  by  diminution  of  the  bactericidal  substances  (A. 
AVassermann),  by  circulatory  disturbances  resulting  from  local  or  gen- 
eral chilling,  by  disturbance  of  circulation  in  intestinal  strangulation,  by 
chronic  inflammation,  by  chemical  or  mechanical  irritation  followed  by 
separation  and  exfoliation  of  epithelium. 

The  fact  that  wounds  of  the  mucous  membranes,  especially  of  the 
nose,  mouth,  and  pharynx,  are  rarely  the  beginning  of  severe  inflam- 
mation, although  constantly  bathed,  as  it  were,  by  bacteria,  which  when 
carried  into  operation-wounds  by  coughing  and  sneezing  cause  inflam- 
mation, appears  to  depend 
upon  the  bactericidal  prop- 
^       ;.' .  erties    of  the   secretion   of 

;^-^^.,.  ;^-    ,  ^^,%,-  "^  the  mucous  membranes  and 

'::>^'  '<,-^  the  leucocytes  which  wan- 

'•£,  der  through  them.    The  rich 

'-{:•  _        >~  ': ,  blood    supply    of    mucous 

^■:'        '  '  membranes,    the    continual 

.,:  '>'.^.'  movement    of    the    saliva, 

and  the  attenuating  effects 
of     symbiotic     saprophytes 
IfiJ       ""»  /\%:-_        are    important    factors    in 

.-"....         this  natural  resistance. 

If  mucous  membranes 
become  infected  with  high- 
JX-'^  Iv  virulent  bacteria  the  in- 
flammation  may  extend  to 
the  submucous  tissues,  pro- 
ducing phlegmons,  may  at- 
tack the  lymphatic  vessels 
and  nodes  or  reach  the 
blood  vessels.  The  rela- 
tions between  acute  angina 
and  articular  rheumatism, 
suppurative  osteomyelitis 
and  metastatic  infection, 
between  enteritis  and  gen- 
eral infection  (vide  Bacterium  Coli  Commune),  are  examples  of  the  ex- 
tension of  infection  through  mucous  membranes  which  are  often  quoted. 
Uninjured  granulation  tissue  is  not  permeable  even  to  highly  virulent 
bacteria  and  their  toxins.  Billroth  showed  that  he  could  keep  putre- 
factive substances  and  pus  in  contact  with  a  large  granulating  wound 
upon  a  dog's  back  for  some  time  without  doing  any  harm.     Noetzel  has 


V, 


%• 


J0' 


,V->^ 


'W 


Fig.  95. — Section  of  a  Tonsillar  Crypt  of  a  Rab- 
bit Which  Died  of  a  General  Bacterial  Infec- 
tion Twenty- FOUR  Hours  After  Three  Drops 
OF  A  High  Virulent  Culture  of  Streptococci 
Were  Rubbed  into  thf;  Mucous  Membrane  Cov- 
ering THE  Tonsil.  The  streptococci  have  in- 
vaded the  Ij'mphoid  tissue  of  the  tonsil,  passing 
through  Stolir's  spaces. 


THE   INFECTION   ATRIA   OF   PYOGENIC   BACTERIA  195 

demonstrated  that  granulating  wounds  of  sheep,  wiiieh  are  very  sus- 
ceptible to  anthrax  and  tetanus,  resist  highly  virulent  cultures.  The 
lessened  susceptibility  of  granulation  tissue  to  infection  was  known  to 
the  old  surgeons,  and  they  desired  to  obtain  in  their  wounds  (e.  g.,  in 
plastic  operations)  good  granulations  as  quickly  as  possible.  The  secre- 
tion of  the  granulation  tissue  removes  the  bacteria  mechanically,  and 
besides  contains  bactericidal  substances  (Afanasieff).  The  cells  of  the 
granulation  tissue,  like  those  of  the  epidermis,  prevent  the  penetration 
of  bacteria,  but  are  not  as  resistant  as  the  latter.  They  are  easily  torn, 
and  if  once  the  thin  veil  covering  the  surface  of  the  granulation  tissue 
is  injured,  the  lymphatic  vessels  and  blood  vessels  stand  open  to  receive 
the  bacteria.  Therefore  Noetzel  was  able  to  produce  fatal  anthrax  or 
tetanus  infections  as  soon  as  he  injured  and  then  infected  the  granulation 
tissue. 

The  experiments  above  cited  agree  with  clinical  experience.  The 
yellowish,  dirty  membrane  consisting  of  secretion  and  colonies  of  bac- 
teria, which  covers  unhealthy  granulation  tissue,  carries  with  it  no  added 
danger,  for  neither  the  bacteria  nor  their  toxins  are  absorbed.  If,  how- 
ever, the  granulating  wound  is  injured  by  traction  upon  the  wound  edges 
during  the  removal  of  adherent  dressings,  by  the  use  of  a  caustic  or 
sharp  spoon,  severe  inflannnation  (lymphangitis,  erysipelas)  may  de- 
velop if  virulent  bacteria — for  example,  streptococci — are  contained 
Avithin  the  granulations. 

The  skin  affords  most  frequently  infection  atria  for  staphylococci 
and  streptococci;  the  mucous  membranes  of  the  mouth  and  pharynx, 
nose,  and  accessory  sinuses,  the  ear  and  respiratory  passages  for  the 
streptococcus  and  pneumococcus ;  of  the  upper  part  of  the  gastrointes- 
tinal canal  for  the  streptococcus  and  staphylococcus;  of  the  lower  part 
of  the  intestine  (likewise  the  bile  passages)  for  the  bacterium  C(tli  com- 
mune, more  rarely  for  the  streptococcus  and  staphylococcus.  In  the 
urinary  passage,  besides  the  gonorrheal  infections,  infections  with  the 
colon  bacillus,  streptococcus,  staphylococcus,  and  bacillus  pyocyaneus 
occur;  in  the  female  genital  canal,  besides  gonori-hea,  infections  Avith  the 
streptococcus  alone  or  associated  with  other  bacteria,  are  most  frequent. 

LiTEKATURE. — Ajauasieff.  Ueber  die  Bedeutung  des  Ciraiiulationsgewebes  bci  dcr 
Infektion  von  Wunden  mit  pathog.  Mikroorganismen.  Zieglers  Beitr.,  Bd.  22,  1897, 
p.  11.— iV.  Bail.  Die  Schleimhaut  des  Magendarnitraktus  als  Eingangspforte  pyog. 
Infektionen.  Arch.  f.  klin.  Chir.,  Bd.  62,  1900,  p.  369.— Buchbinder.  Kxperim.  I'nter- 
suchungen  am  lebenden  Tier-  u.  Menschendarm.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  55, 
1900,  p.  4o8.—Helmberger  und  Martina.  Exi)erim.  rntersuchungen  iiber  die  Durch- 
gangigkeit  des  Darmes  f.  Bakt.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  74,  1904,  p.  527. — 
Jilrgeliinas.  Ueber  die  Durchgangigkeit  des  Granulationsgewebes  f.  pathog.  Mikro- 
organismen. Zieglers  Beitr.,  Bd.  29,  1901. — Lexer.  Die  8chleimhaut  iles  Rachens  als 
Eingangspforte  pyog.  Infektionen.     Arch.  f.  klin.  Chir.,  Bd.  54.  1S97.  p.  73G. — Xdtzel. 


196  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

Ueber  die  Infektion  granulierender  Wundeii.  Chir.-Kongr.  Verhandl.,  1897,  IF,  p. 
272  and  Arch.  f.  klin.  Chir.,  Bd.  5."),  p.  543. — Schimmelbusch.  Ueber  d.  Ursacheiid. 
Furunkel.  Arch.  f.  Ohrenheilkunde,  188'.),  Bd.  27,  p.  252. — Wasmulh.  Ueber  die  Durch- 
gangigkeit  der  Haut  fiir  Mikroben.  Zentralbl.  f.  Bakteriol.,  Bd.  12,  1892,  p.  824.— A. 
W assermann.  Infektion  und  Autoinfektion.  Deutsche  med.  Wochenschr.,  1902 
I).  117. 


CHAPTER    III 

PYOGENIC    INFECTIONS   AND   THEIR   TREATMENT 

The  invasion  of  the  tissues  follows  closely  the  infection  of  the  wound 
with  pyogenic  bacteria.  Pyogenic,  like  all  other  bacteria,  require  a 
certain  but  short  period,  the  so-called  incubation  period,  before  they 
actively  invade  the  tissues.  During  this  time  they  multiply,  their  viru- 
lence increases  by  growth  upon  the  good  culture  media  furnished  by  the 
tissues,  and  their  own  power  is  increased  and  the  development  of  bac- 
tericidal substances  in  the  wound  secretion  is  retarded. 

After  the  invasion  of  a  wound  or  of  the  uninjured  mucous  mem- 
brane or  skin  the  bactericidal  substances  and  protective  mechanism  are 
able  to  cope  for  the  time  being  with  the  bacteria.  The  beginning  strug- 
gle between  the  bacteria  and  the  tissues  with  its  victories  and  defeats 
pursues  an  acute,  rarely  a  chronic  course,  which  usually  but  not  always 
ends  in  suppuration.  If  the  bacteria  are  weak  and  few  in  number,  they 
succumb  to  the  bactericidal  substances  in  the  tissue  fluids  and  the  in- 
flammation is  mild,  ending  without  pus  formation.  No  pus  may  be 
formed,  but  extensive  necrosis  may  result  when  the  bactericidal  substances 
are  too  weak  to  resist  the  numerous  and  highly  virulent  bacteria.  Be- 
tween the  mild  and  virulent  infections  there  is  a  variety  which  ends  in 
pus  fo'rmation.  When  the  struggle  between  the  bacteria  and  tissues  is 
about  even,  pus  is  formed.  The  invasion  of  new  tissue  indicates  a  vic- 
tory for  the  bacteria,  while  the  subsidence  of  the  inflammation  and  the 
encapsulation  of  the  pus  indicate  that  the  bactericidal  substances  of  the 
tissues  have  ])i"evailed.  An  acute  suppurative  inflammation  is  there- 
fore characteristic  of  pyogenic  infections,  although  other  forms  of  inflam- 
mation, excepting  the  putrefactive  forms,  may  be  present  {vide  Inflam- 
mation). 

If  bacteria  and  their  toxins  are  absorbed  the  struggle  is  transferred 
to  the  whole  body  and  becomes  general.  IMore  forces  are  then  at  the 
disposal  of  the  organism  to  combat  the  infection,  which,  however,  are 
often  denied  when  the  infection  is  vij-ulent  or'  the  general  condition 
poor.      A   lymphogenous   or   ha-nuitogenous    infection,    depending   upon 


PYOGENIC   INFECTIONS  AND   THEIR  TREATMENT  1!)7 

whether  it  is  carried  by  the  lymph  or  blood  stream,  is  distinguished  from 
an  ectogenous  infection  in  which  the  bacteria  gain  access  from  the  outer 
world,  and  an  endogenous  infection  in  which  the  bacteria  have  h\in  dor- 
mant for  some  time  upon  the  mucous  membranes  (e.  g.,  of  the  intestine 
or  bladder)  or  in  an  old  encapsulated  focus. 

The  action  of  pyogenic  bacteria  as  of  all  pathogenic  micro-organisms 
depends  upon  their  ability  to  produce  toxins  during  their  growth  in  the 
tissue,  and  in  their  death  and  solution  to  liberate  their  protoplasmic 
toxins. 

The  methods  which  should  be  employed  in  the  treatment  of  pyogenic 
ir.feetions  depend  upon  the  cause  of  the  infection,  the  character  of  the 
intiannnation,  and  the  complications  and  sefjuehe  which  most  frequently 
follow.  The  treatment  should  in  no  way  interfere  with  the  inflammatory 
jH'ocesses  which  combat  the  infection,  and  should  therefore  not  be  anti- 
phlogistic. The  tissues  involved  should  be  aided  in  their  struggle  against 
the  bacteria,  and  the  inflamed  part  should  be  kept  (juiet  by  an  immo- 
bilizing dressing  and  protected  from  external  injury,  and  the  infiamed 
area  shoidd  be  incised  to  permit  of  the  escape  of  the  bacteria  and  their 
toxins,  in  this  way  lessening  their  action.  If  efficient  treatment  is 
instituted  early,  the  tissues  will  be  aided  in  their  struggle  against  tlie 
bacteria  and  will  overcome  the  infection  with  but  little  destruction  of 
tissue. 

Absolute  Eest,  Obtained  by  Immobilizing'  Dressings,  Elevation,  etc. — 
In  the  beginning  of  any  intiannnation  absolute  rest,  obtained  l)y  the  use 
of  an  immobilizing  dressing  which  exerts  no  pressure  is  of  great  im- 
portance. Frequently  it  alone  Avill  control  mild  inflammation  and  cause 
it  to  subside.  Suspension  or  elevation  of  an  inflamed  extremity  is  use- 
ful, as  it  favors  the  venous  return  and  prevents  stasis  in  the  inflamed 
area,  which  hastens  the  destruction  of  tissue. 

Frequently  well-fltting  bandages  combined  with  elevation  will  alle- 
viate the  pain  resulting  from  the  inflammation.  Its  action  is  increased 
if  dressings  covered  with  an  ointment  (Ave  to  ten  per  cent  zinc  oxide  or 
boric  vaseline)  are  used,  as  they  impart  to  the  tense,  inflamed  skin  a 
pleasant,  cool  sensation.  The  ointments  have  this  advantage,  that  they 
do  not  macerate  the  skin  as  moist  dressings  do,  and  besides  they  may  be 
allowed  to  remain  in  position  a  long  time  (a  number  of  days),  and  then 
there  is  no  occasion  to  disturb  the  immobilizing  dressing. 

Cold  in  the  form  of  an  ice  bag  has  been  used  extensively  because 
it  controls  pain.  Applied  for  a  short  time  in  superficial  inflammation, 
it  lessens  the  hyperaemia  by  contracting  tho  blood  vessels  and  delays  tbe 
inflammatory  process.  If  used  for  a  longer  time  there  is  an  increased 
tendency  to  stasis,  and  necrosis  may  occur.  The  ice  bag  is  to  be  recom- 
mended for  the  control  of  pain  only  when  the  deeper  tissues  are  inflamed. 
14 


198 


WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 


or  in  peritonitis  when  one  hopes  to  delay  the  inflammatory  process  and 
to  localize  or  encapsulate  the  inflannnation. 

Hot,  Moist  Compresses. — Moist  compresses  (three  per  cent  acetate  of 
aluminum,  or  boric  acid  solution,  ninety-five  per  cent  alcohol  according 

to  Salzwedel,  with  or  without  a 
rubber  or  gutta  percha  covering) 
control  the  pain,  but  often  in- 
jure the  skin.  In  mild  inflam- 
mations, the  moist  compress,  with 
the  help  of  the  hyperemia  which 
it  induces,  often  causes  the  in- 
flammation to  subside  without 
suppuration.  In  severe  inflam- 
mation.s,  on  the  other  hand,  moist 
compresses  produce  an  increased 
exudation,  the  result  of  the 
greater  hyperoemia.  The  in- 
creased pressure  in  the  inflamed 
area  then  drives  the  bacteria  and 
their  toxins  into  the  surrounding 
tissues,  and  the  tissues  become 
necrotic  and  are  liquefied  by  the 
ferments  in  the  pus.  For  this 
reason  moist  compresses  and  still 
more  hot  poultices  (cataplasms) 
hasten  and  increase  the  destruc- 
tion of  tissues  and  the  formation 
of  pus.  For  example,  a  subcu- 
taneous felon  treated  for  eight 
days  by  poultices  extends  to  the  tendon  and  bone  {.vide  Fig.  96).  The 
author  has  observed  a  complete  sequestration  of  the  glandular  substance 
of  the  br(»ast  in  a  mastitis  which  was  treated  for  two  weeks  with  poul- 
tices. ]\Ioi.st  compresses  may  be  used  in  large,  deep-lying,  indurated 
areas  to  "  ripen  the  abscess  "  so  that  the  knife  may  be  used. 

It  is  a  gross  error,  but  one  which  is  frequently  made,  to  use  an  ice 
bag  or  moist  compress  upon  the  extremitic^s  in  place  of  the  immobilizing 
dressing. 

Incision  of  Abscess  and  Evacuation  of  Pus. — As  soon  as  pus  is  demon- 
strated by  the  sensation  of  fluctuation,  or  suspected  because  of  the  loca- 
tion of  or  increase  in  size  of  the  swelling  (e.  g.,  in  submaxillary  region 
in  periostitis  of  the  mandible,  inflammation  of  tendon  sheath  of  the 
hand),  or  because  of  the  clinical  .symptoms  alone  (e.  g.,  in  the  body  cavi- 
ties), an  incision  should  be  made  and  the  pus  allowed  to  escape.     The 


Fig.  96. — A  Felon  of  the  Index  Finger  As- 
sociated WITH  Necrosis  of  the  Flexor 
Tendon  and  Destruction  of  the  Joints 
Following  an  Injury  of  the  Skin.  Re- 
sult of  two  weeks'  treatment  with  poul- 
tices. 


PYOGENIC    INFECTIONS   AND   THEIR  TREATMENT  1<J9 

incision  should  be  large  enough  to  permit  of  the  escape  of  the  pus, 
and  to  reduce  the  tension  of  the  tissues.  In  making  the  incision  the 
tissues  should  be  divided  layer  by  layer,  as  in  this  way  the  important 
anatomical  structures  may  be  most  easily  avoided.  Puncture  of  an  ab- 
scess alone  or  drainage  through  a  small  opening  is  always  insulTicient, 
as  is  also  the  expectant  treatment,  in  which  the  pus  is  allowed  to  break 
through  the  skin.  Deep  suppurating  foci  in  Ixme,  in  the  brain  and  skull, 
and  in  the  thorax  should  be  rendered  accessible  by  special  operations. 

Anassthesia  and  ischaBmia  of  the  part  involved  (excepting  in  case  of 
accompanying  lymphangitis)  are  indispensable  in  opening  large  phleg- 
mons and  deep-lying  abscesses  if  the  operator  wishes  to  find  all  the 
recesses,  and  to  avoid  all  the  important  nerves,  ligaments,  etc. 

The  method  of  local  anaesthesia  suggested  by  Oberst  is  best  suited 
for  opening  abscesses  of  the  finger  tips.  In  this  method  a  piece  of  rubber 
tubing  is  applied  about  the  base  of  the  proximal  phalanx,  and  then  the 
cocain  is  injected  into  healthy  tissues  along  the  course  of  the  sensorv^ 
nerves  (vide  Local  Anaesthesia).  Injections  should  not  be  made  into 
the  inflamed  tissue,  as  in  Schleich's  method,  as  the  bacteria  may  be 
forced  into  the  surrounding  and  deeper  tissues. 

Small  abscesses,  furuncles,  and  small  carbuncles  may  be  incised  after 
the  area  has  been  frozen  with  ethyl  chloride.  The  tissues  are  frozen  more 
rapidly  with  this  than  with  the  ether  spray. 

Avoidance  of  Mechanical  and  Chemical  Irritation. — The  incised  wound 
should  not  be  irritated  mechanically  or  by  chemicals.  The  infected  tis- 
sues are  injured  and  their  resistance  reduced  by  pressure,  sponging,  irri- 
gation, washing  out  of  pus,  or  the  curetting  of  necrotic  tissue,  by  sep- 
arating tissues  with  fingers  or  hooks,  by  probing  the  wound — in  short,  by 
all  rough  procedures.  As  a  consequence  of  such  manipulations,  bacteria 
or  their  toxins  may  be  forced  into  the  blood,  and  the  lymph  vessels  or 
thrombi  may  be  separated.  Then,  instead  of  the  fever  falling  after  the 
incision  and  the  inflammation  subsiding,  it  extends,  accompanied  by  chills 
and  fever,  or  lymphangitis  or  erysipelas  develops  about  the  edges  of  the 
wound,  or  dangerous  lung  embolism,  metastatic  inflammation,  or  general 
infection  results. 

Chemical  irritation  leads  to  a  superficial  necrosis  of  the  surfaces  of 
the  wound.  Pure  carbolic  acid,  as  recommended  by  von  Bruns  to  be 
applied  for  one  minute,  has  certainly  an  immediate  sterilizing  action, 
but  the  eschar  which  it  forms  prevents  the  discharge  of  the  exudate 
loaded  with  bacteria  and  toxins,  and  these  are  driven  into  new  paths. 
The  ordinary  antiseptic  solutions  do  not  injure  the  tissues  if  they  act 
for  a  short  time,  but  they  likewise  have  no  effect  upon  the  bacteria  in 
them.  They  kill  only  those  bacteria  upon  the  surface  of  the  wound, 
and  must  act  for  some  time  even  to  produce  this  result.     The  tissues 


200  WOUND    INFECTIONS   PRODUCED    BY    BACTERIA 

are  injured,  their  resistance  is  reduced,  or  they  become  necrotic  {vide 
Carbolic  Necrosis)  when  antiseptic  solutions  are  used.  Paste-like  agents 
(Schleich's  wound  preparations,  giutol,  glutol-serum)  and  powders 
(iodoform,  subnitrate  of  bismuth)  should  not  be  used,  as  they  form  a 
crust  which  prevents  the  discharge  of  the  secretion. 

Tampon  and  Tubular  Drainage. — A  freshly  incised  wound  should  be 
loosely  tamponed  with  iodoform  gauze,  which  should  provide  drainage 
for  all  the  recesses  and  cavities.  Dry  gauze  placed  in  a  wound  acts  in 
two  ways,  it  controls  the  haemorrhage  and  removes  by  its  capillarity  in- 
fectious materials,  and  therefore  retards  the  post-operative  absorption. 
The  exudate  and  blood  lying  in  the  recesses  of  the  wound  and  seeping 
from  the  tissue  are  carried  by  the  capillarity  of  the  gauze  into  the 
dressings.  Moist  gauze  saturated  with  antiseptic  solution  has  no  such 
action.  As  moist  gauze  dries  it  acquires  capillarity,  and  then  resembles 
more  closely  in  its  action  iodoform  gauze.  The  bactericidal  action  of 
gauze  saturated  with  antiseptics  when  compared  to  the  action  of  dry 
gauze  is  of  secondary  importance. 

In  deep  wounds  with  recesses  the  tampon  should  be  combined  with 
tubular  drainage.  A  large  rubber  drain  should  be  inserted  into  the 
deepest  part  of  the  wound,  and  this  should  be  surrounded  by  iodoform 
gauze.  The  moist  tampon,  evaporation  from  which  is  prevented  by  a 
rubber  covering,  has  no  capillarity  whatever.  This  alone  is  enough  to 
condemn  this  dressing,  but  there  is  still  another  objection,  as  bacteria 
multiply  rapidly  within  the  gauze  in  spite  of  the  antiseptics  it  contains, 
upon  the  skin,  and  within  the  wound. 

The  tampon  should  not  be  removed  for  twenty-four  hours,  for  usually 
the  surface  of  the  wound  is  then  freshly  injured  and  absorption  is  fa- 
vored. The  tampon  should  be  changed  at  the  end  of  forty-eight  hours,  as 
it  then  no  longer  conducts  away  the  wound  secretion,  but  prevents  the 
discharge  of  that  which  is  newly  formed. 

Care  should  be  exercised  in  changing  tampons  and  dressings  to  avoid 
injuring  the  wound  surfaces  and  providing  new  infection  atria.  The 
tampon,  if  adherent,  should  be  moistened  with  a  three  per  cent  hydrogen 
peroxide  solution,  and  with  the  development  of  the  foam  the  gauze 
becomes  loosened,  and  can  be  removed  without  the  least  htemorrhage. 

The  greatest  care  should  be  exercised  at  each  dressing.  Thick  pus 
formed  in  large  amounts  may  be  made  to  flow  from  deep  wounds  by 
changing  the  position  of  the  patient,  oi-  may  be  removed  by  careful  irri- 
gation with  sterile  M'ater  (without  pressure),  or  may  be  gently  wiped 
away.  Pus  upon  tlu^  sui'face  of  a  wound  does  less  injury,  even  when 
allowed  to  remain,  than  the  r-ough  attempts  at  removal,  which  may 
be  followed  by  lymphaiigiti.s,  erysipelas,  fever,  etc.  The  edges  of  the 
wound  should  be  covered  with  an  ointment  to  prevent  the  dressings  from 


PYOGENIC    INFECTIONS   AND   Tlll^ril   TREATMl-.XT  201 

becoming"  adherent.  tSterile  gauze  or  mull,  imprctiiiated  with  some  suh- 
stitute  for  iodoform  (dermatol,  xerol,  Crede's  silver  preparation,  etc.), 
may  be  used  instead  of  iodoform  gauze  if  there  is  a  tendency  to  eczema. 

The  incised  wound  must  be  kept  open  by  a  superficial  tampon,  oi- 
drained  as  long  as  the  discharge  of  pus  is  profuse.  The  conditions  in 
the  wound  change  after  a  few  days,  and  the  line  of  treatment  must  be 
changed  to  meet  conditions.  The  tampon  takes  up  the  blood,  the  tissue 
fluids,  and  the  remaining  pus  from  the  surfaces  of  freshly  incised  sup- 
purating wounds.  After  a  few  days,  wiien  the  granulation  tissue  de- 
velops and  the  necrotic  tissue  becomes  separated,  the  wound  discharges 
a  thick  creamy  pus  which  iodoform  gauze  will  not  drain.  AVhen  the  i)iis 
becomes  thick  and  creamy  a  tubular  drain  should  be  inserted  into  the 
deep  parts  of  the  wound. 

In  such  conditions  ointment  dressings  or  moist  compresses  without 
the  covering  of  rubber  tissue  are  indicated.  They  produce  a  mild  irri- 
tation resulting  in  hyperaemia,  which  hastens  the  separation  of  necrotic 
particles,  thins  the  pus  by  increasing  the  exudate,  and  cleanses  the  graini- 
lating  surfaces.  If  the  pus  or  the  membrane  covering  the  granulation 
tissue  is  removed  mechanically,  there  is  always  the  danger  of  new  in- 
fection, for  the  granulating  surface  absorbs  as  soon  as  it  is  injured. 

Mercury  ointments  (unguentum  hydrargyri  cinereum,  h.vdrarg. 
oxyd.  rubr.,  four  to  eight  per  cent  with  vaseline;  mild,  ten  per  cent 
zinc  salve)  are  best  suited  for  these  cases.  Three  per  cent  acetate  of 
aluminum,  two  per  cent  boric  acid  solution  and  alcohol  are  used  for 
moist  dressings,  and  if  the  evaporation  is  not  prevented  by  the  use  of 
rubber  tissue,  the  gauze  as  it  di-ies  ae(iuires  a  strong  capillary  action 
(vide  p.  29). 

The  treatment  of  healthy  granulating  incised  wounds  is  the  same  as 
that  of  a  fresh  wound  healing  by  granulation  tissue.  Innnobilizing  of 
the  inflamed  part  and  rest  in  bed  should  be  maintained  until  the  tense 
reddened  skin  becomes  shrunken  and  pale,  the  temperature  falls,  and  the 
coated  granulations  become  clean.  A  dressing  poorly  applied  pei-mifs 
of  muscular  action  which  injures  the  inflamed  tissues.  Bandages  which 
exert  pressure  and  constrict  the  parts  produce  circulatory  disturbances, 
retard  the  escape  of  wound  secretion,  and  favor  the  extension  of  the 
inflammation.  One  should  therefore  learn  to  ]>roperly  apply  a  l)Mn(lage 
in  acute  inflamnuitions.  Von  Yolkmann's  wooden  splint  or  a  simple 
papier  mache  splint,  well  padded,  may  be  used  to  inunobili/.e  the 
extremities. 

Prophylaxis. — Prophylaxis  is  an  important  factor  in  tlu>  tn  atment  of 
all  acute  suppurative  and  putrefactive  infections.  xVll  patients  with 
erysipelas,  phlegmons,  suppurative  osteomyelitis,  metastatic  infections, 
etc.,  should  be  placed  in  an  isolation  ward,  which  every  well  regulated 


202  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

hospital  should  have  at  its  coniniand.  The  staff  of  this  isolation  ward 
should  not  have  access  to  the  operating  room  or  any  other  ward.  While 
dressing-  patients  the  physician  should  wear  rubber  gloves  to  protect  his 
hands,  and  remove  the  saturated  dressings  with  large  dressing  forceps, 
for  it  is  possible  to  transfer  bacteria  into  other  wounds  when  the  fingers 
have  been  in  contact  with  pus,  even  when  the  hands  have  been  thoroughly 
sterilized.  (For  the  same  reason  a  surgeon  should  always  wear  rubber 
gloves  when  he  performs  an  autopsy.)  It  scarcely  need  be  emphasized 
that  the  gown  should  be  changed  after  the  dressings  have  been  completed. 
Concerning  the  use  of  Bier's  passive  hyperaeniia  in  acute  infections, 
see  Chapter  VII,  page  310. 


CHAPTER    IV 

THE   PYOGENIC    INFECTIONS    OF    DIFFERENT    TISSUES 

(a)     THE   PYOGENIC    INFECTIONS   OF   THE   SKIN   AND 
SUBCUTANEOUS   TISSUES 

FURUNCLE 

If  the  pyogenic  micro-organisms  which  inhabit  the  epidermis,  or  are 
transferred  to  it  from  neighboring  suppurating  foci  or  by  infected 
fingers  are  forced  into  the  pores  of  the  skin  by  rubbing,  a  circumscribed 
inflammation  develops  (Garre,  Bockhart,  Schimmelbusch).  The  bac- 
teria gain  access  nnich  more  easily  to  the  points  at  which  the  hairs  pierce 
tlie  skin  than  to  the  tortuous  ducts  of  sweat  glands,  and  so,  as  a  rule,  the 
cocci  develop  along  the  shaft  of  the  hair  or  lanugo  hair  and  reach  the 
hair  follicle  and  its  sebaceous  gland  (Sehimmell)useh,  vide  p.  193). 

They  produce  a  circumscribed,  acute,  suppurative  inflammation,  the 
central  point  of  which  is  the  hair  which  provided  the  infection  atrium. 
The  hypera'inia  and  exudation  into  the  tissues  produces  within  a  few 
days  a  round,  somewhat  elevated,  deep  red,  hard  nodule,  which  develops, 
accompanied  by  an  increasing  burning  pain,  sometimes  to  the  size  of  a 
pea,  sometimes  to  that  of  a  cherry.  The  formation  of  pus  causes  an 
elevation  of  the  epidermis  in  the  center  of  the  red  area,  and  a  yellow 
pustule  develops  at  the  base  of  the  hair  involved.  After  the  pus  is  dis- 
charged the  small  inflammatory  focus  heals.  In  large  furuncles  there 
is  a  necrosis  of  tissue.  The  hair  follicle  and  sebaceous  gland  from 
which  the  bacteria  penetrate  into  the  deeper  surrounding  tissues  are 
destroyed,  'i'lic  larger  the  inflammatory  focus  becomes,  the  greater  the 
amount  of  1  issue  surrounding  it  destroyed.     The  necrotic  tissue  which  is 


THE   PYOGExNIC   INFECTIONS   OF   DIFFERENT  TISSUES         203 

separated  by  the  pus  has  the  form  of  a  cone,  the  apex  of  which  extends 
into  the  subcutaneous  tissues.  Left  alone,  the  necrotic  tissue  or  "  core  " 
is  extruded  or  liquefied  after  one  or  two  weeks.  The  space  left  in  the 
tissues  after  the  removal  of  the  "  core  "  is  filled  in  by  pranulation  tissue 
and  healinii'  occurs,  while  the  reddened  area  disapi)ears  within  another 
week. 

Bacteria  Found  in  Furuncles. — The  type  of  inflammation  above  de- 
scribed is  the  furuncle  or  boil ;  smaller  and  larger  foci  may  be  regarded 
as  varieties  of  the  same.  The  most  frequent  causes  of  the  furuncle  are 
different  varieties  of  the  staphylococcus,  particularly  the  aureus  and 
albus,  yet  streptococci  may  be  found  which,  in  spite  of  the  stubborn 
course  of  the  infecticns,  produce  at  most  a  pustule,  but  no  extensive 
necrosis.  The  furuncle  is  therefore  most  often  a  staplnjloDiycosis  circum- 
scripta cutis  (Kocher). 

Etiological  Factors:  Mechanical  Irritation,  TJncleanliness,  Diabetes, 
etc. — Furuncles  develop  most  freipiently  upon  parts  of  the  body  which 
are  exposed  to  mechanical  irritation  (rubbing  by  clothing)  and  which 
are  often  unclean  (nates,  inner  surface  of  the  thigh,  axillary  fossa,  neck). 
They  develop  also  in  inflamed  areas  (resulting  from  eczema,  prurigo, 
urticaria,  scabies,  and  vermin  of  all  sorts)  which  are  scratched.  They 
may  develop  sinuiltaneously  in  different  parts,  or  stubborn  reinfections 
may  develop  in  a  patient  whose  resistance  to  pyogenic  infections  has  been 
reduced  by  some  disease  (diabetes,  cachexia,  marasmus).  In  those  parts 
in  which  comedones  are  frequent  (face  and  back),  furuncles  are  often 
intermingled  with  the  harmless  acne  pustules  or  develop  from  them.  If 
a  furuncle  develops  after  an  insect  sting  or  bite,  it  is  hard  to  say  whether 
the  infection  was  transferred  by  the  insect  or  by  the  fingers  when  scratch- 
ing, A  typical  furuncle  develops  after  a  prick  with  a  needle  infected 
with  staphylococci.  In  the  palms  of  the  hands  and  the  soles  of  the 
feet  furuncles  rarely  develop,  as  there  are  no  hair  follicles.  If  they  do 
develop  here  the  sweat  glands  or  slight  injuries  afford  the  infection 
atrium. 

Complications:  Lymphangitis,  Lymphadenitis,  General  Infections,  etc. 
— As  a  rule,  a  progressive  inflammation  does  not  develop  from  a  single 
furuncle.  The  inflammation  remains  circumscribed,  and  after  the  ex- 
trusion of  the  necrotic  center  ("  core  ")  there  is  a  tendency  to  heal. 
Healing  occurs  spontaneously,  as  a  rule,  in  from  two  to  three  weeks.  In 
spite  of  this  every  furuncle  carries  with  it  a  number  of  dangers.  In  the 
first  place,  the  pus  discharged  by  an  open  boil,  which  is  not  dressed,  may 
be  carried  by  the  clothing,  fingers,  or  poultices  to  surrounding  skin. 
Other  furuncles  are  produced  in  this  way,  which  in  diabetics  or  in  weak 
nursing  children  may  extend  over  the  entire  body  (furunculosis).  In 
the  second  place  the  bacteria  may  enter  the  lymph  or  blood  vessels.    Fre- 


204  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

quently  infectious  substances  are  absorbed  from  a  single  boil,  and  there 
is  an  elevation  of  temperature  accompanied  by  the  other  symptoms  of 
fever.  It  is  easily  understood  why  lymphangitis  and  lymphadenitis  fre- 
quently develop;  this  happens  frequently  with  furuncles  of  the  hands 
and  feet  as  the  movements  of  the  clothing  favor  the  entrance  of  the 
cocci  into  the  lymphatic  spaces.  Blood  infections  may  develop  from 
furuncles.  In  these  cases  the  bacteria  either  invade  the  capillaries  and 
small  veins,  infected  thrombi  are  loosened  spontaneously  or  by  rough 
manipulations  (pinching  of  the  furuncle,  curettage  after  incision),  or 
a  large  vein  (facial,  saphenous)  adjacent  to  the  furuncle  becomes  in- 
flamed. Any  furuncle  may  become  dangerous  by  causing  general  pyo- 
genic infections  (osteomyelitis,  metastatic  suppuration  of  joints,  vis- 
cera, etc.),  and  this  should  be  kept  constantly  in  mind  during  the 
treatment. 

Varieties  of  Furuncles. — Carbuncles. — Carbuncles,  the  worst  form  of 
furuncle,  Avhich  develop  frequently  in  old  age,  in  children,  and  young 
adults,  are  often  associated  with  these  dangers.  A  carbuncle  develops 
as  the  result  of  simultaneous  infection  of  adjacent  hair  follicles,  or  when 
hair  follicles  adjacent  to  a  furuncle  become  infected  by  the  pus  dis- 
charged from  it.  It  is  characterized  by  considerable  pain  and  swelling, 
rapid  growth,  extensive  destruction  of  tissue,  high  fever,  and  severe 
general  symptoms.  The  center  of  the  bluish  red,  infiltrated  area,  which 
rises  about  two  fingers'  breadth  above  the  healthy  surrounding  skin  and 
gradually  slopes  into  it,  contains  pustules  and  necrotic  tissue,  or  is  cov- 
ered by  a  ha?morrhagic,  purulent  crust  or  gangrenous  skin.  If  the  inflam- 
mation extends  or  new  furuncles  develop  as  the  result  of  improper  (poul- 
tices) or  no  treatment,  the  carbuncle  rapidly  increases  in  size  and  may 
become  in  from  one  to  two  weeks  as  large  as  a  hand  or  a  small  plate 
(Fig.  97).  The  inflannnation  then  extends  to  the  fascia  covering  the 
muscles;  the  tissues  become  infiltrated  and  riddled  with  small  purulent 
and  necrotic  foci.  The  tissues  in  the  center  of  the  carbuncle  are  de- 
stroyed, and  frequently  the  necrosis  extends  so  deep  that  pieces  of  the 
fascia  are  extruded.  Thrombophlebitis  of  the  subcutaneous  veins  may 
develop,  \\liicli  favors  the  extension  of  the  inflannnation  to  neighboring 
tissues;  in  carbuncle  of  the  upper  lip  the  facial,  the  angular,  superior 
ophthalmic  veins  may  become  involved,  and  process  may  extend  to 
meninges  through  the  cavernous  sinus,  or  give  rise  to  a  general  pyogenic 
infection. 

The  l^-mphangilis  associated  with  ear])uncles  of  the  extremities  is 
easily  seen.  Often  the  neighboi-ing  lymph  nodes  su]ipui'ate.  In  weak 
individuals  and  (lial)etics  a  (•ai'l)uncle  may  pi-oduce  a  chronic  febrile 
condition  which  may  lead  to  cachexia  and  death,  without  meningitis  or 
metastatic  foci  developing. 


THE   PYOGENIC    INFECTIONS   OF   DIFFERENT   TISSUES 


205 


The  development  of  a  carbuncle  depends  partly  upon  the  condition  of 
the  patient— e.  g.,  diabetes — and  partly  upon  the  virulence  of  the  bacteria. 

Besides  staphylococci,  all  possible  forms  of  pyogenic  bacteria,  particu- 
larly the  streptococci,  may  be  found  in  a  carbuncle.  According  to 
Kocher,  the  strepto- 
cocci alone  may  pro- 
duce this  variety  of 
inflammation.  Fre- 
quently they  develop 
from  furuncles  which 
have  been  pinched  or 
stuck  by  the  patients 
themselves,  or  after 
the  use  of  moist  dress- 
ings or  poultices,  which 
increase  and  hasten 
suppuration  and  ne- 
crosis, macerate  the 
healthy  skin  surround- 
ing the  furuncle,  and 
inoculate  it  with  pus 
which  is  not  absorbed 
by  the  dressing. 

Folliculitis  BarhcB. 
— Those  inflammations 
which  are  limited  to 
the  hair  follicle  and 
its  sebaceous  gland 
(folliculitis)  are  harmless  forms  of  furuncles.  In  hairy  parts  small 
pustules  with  little  infiltration  develop.  If  the  hair  is  removed,  and 
with  it  the  thick  pus  surrounding  its  root,  the  inflammation  subsides 
in  a  few  days.  If  in  the  beard,  the  infection  extends  from  one  hair 
follicle  to  another,  the  stubborn  sycosis  or  folliculitis  barbtv  develops, 
which  demands  the  irksome  removal  of  all  the  hairs,  the  opening  of 
all  newly  formed  pustules,  and  the  use  of  salve  dressings. 

Other  forms  of  follicular  inflammation  develop  upon  parts  of  the 
face  and  back  where  comedones  occur.  The  duct  of  the  sebaceous  gland, 
occluded  by  dirt,  dilates  the  opening  at  which  the  lanugo  hair  pierces 
the  skin  to  such  an  extent  that  an  infection  atrium  is  provided. 

Frequently  the  expression  of  the  comedo  with  fingers  infected  by 
pus  from  an  adjacent  pustule,  or  which  arc  dirty,  is  the  exciting  cause. 
A  blackhead  occupies  the  center  of  the  small  red  furuncle,  which  is 
never  larger  than  a  pea.     This  form  of  furuncle  develops  frequently  in 


Fig.  97. — Large  Carbuncle  of  the  Neck  Developing 
FROM  A  Furuncle  in  Two  Weeks  Under  Treatment 
■WITH  Poultices.  The  patient  is  a  powerful  nondiabetic 
man. 


206 


WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 


unclean  individuals  in  whom  there  is  a  tendency  to  comedones,  particu- 
larly at  the  age  of  puberty.  It  has  been  called  acne  punctata,  or  if  a 
pustule  forms,  acne  pustulosa.  An  inflammation  of  the  cilia  and  their 
sebaceous  glands  (Meibomian  glands)  is  called  a  hordeolum. 

Prognosis. — Healing  occurs  within  a  few  days  after  rupture  or  re- 
moval of  the  pustule  with  forceps  or  by  incision.  The  inflammation  per- 
sists if  the  inflamed  area  is  repeatedly  pinched  by  the  patient,  or  the  pus 
carried  into  surrounding  tissues  and  neAV  furuncles  develop. 

Diagnosis. — The  diagnosis  of  the  carbuncle  offers  the  most  difficulties, 
for  it'  may  be  confused  with  the  carbuncle  produced  by  anthrax,  for  the 
latter  may  develop  a  pustule  when  there  is  secondary  infection.  The 
microscopic  demonstration  of  the  anthrax  bacillus  settles  the  diagnosis. 
Treatment. — The  treatment  of  a  furuncle  should  promote  rapid  heal- 
ing and  prevent  the  development  of  other  furuncles.  If  the  furuncle 
is  so  situated  that  it  is  exposed  to  friction,  it  must  be  protected  by  a 
gauze  dressing,  which  is  retained  in  position  by  adhesive  plaster.     In 

this  way  it  is  protected  from 
irritation  from  without,  and 
the  pus  discharged  from  it  is 
not  carried  to  adjacent  skin. 
If  the  infiltration  increases 
rapidly,  although  the  furuncle 
has  discharged  spontaneously 
or  has  been  opened  (removal 
of  the  hair,  opening  with  tis- 
sue forceps),  it  should  be 
incised. 

After  sterilization  of  the 
skin  an  incision  is  made  un- 
der ethyl  chloride  ana'sthesia, 
as  wide  and  deep  as  the  infil- 
tration extends.  Some  layers 
of  iodoform  gauze  are  placed 
in  the  wound,  and  when  these 
are  removed  twenty-four  hours 
later  the  completely  separated 
core  will  be  found  attached 
to  it.  Large  furuncles  heal 
undei'  this  dry  and  sparing 
treatiiiciit  in  one  week  witli- 
""t  any  s.-(|ncl!e.  A  small  salve  dressing  is  applied  after  the  core  is 
••xtnid.'d.     Af   each  dressing  the  surrounding  area  should  be  sterilized 

Willi    Jllcoliol. 


1'  i(j.  M.S.— TiiK  Samio  Case  Imght  Days  After 
Di'KnATioN.  Healthy  granulation  tissue  has 
developed  and  the  four  flaps  whicli  were  dis- 
sected free  to  tlu'ir  bases  are  again  united. 


THE   PYOGENIC   INFECTIONS   OF    DIFFERENT  TISSUES  207 

Moist  Dressings  and  PouUiccs. — IMciist  dfcssinus  and  poultices  has- 
ten the  softening-  of  the  furuncle,  but  do  not  hasten  repair.  The  infil- 
tration increases,  tlie  neci-otic  core  becomes  lar<ier,  while  the  pus  under 
the  dressing  infects  healthy  surrounding  skin,  wiiich  is  macerated  and 
made  more  susceptible  to  infection.  As  a  ride  a  nund)er  of  other  fu- 
runcles develop  when  moist  dressings  are  used.  Moist  antiseptic  dress- 
ings have  as  little  effect  upon  the  bacteria  in  the  surrounding  skin  as 
they  do  upon  those  in  the  furuncle. 

In  the  large  furuncles  and  carbuncles  a  simple  incision  is  never  suf- 
ficient. A  crucial  incision  must  be  made  under  general  anaesthesia. 
The  flaps  formed  in  this  way 
are  held  apart  with  retract- 
ors, and  an  incision  is  made 
so  that  the  infiltrated  tissue 
is  separated  from  the  healthy, 
and  the  entire  inflannnatory 
focus  is  exposed.  The  cor- 
ners of  the  flaps  are  either 
necrotic,  or  wall  become  so, 
so  it  is  best  to  remove  them 
at  once.  The  wound  is  kept 
wide  open  to  permit  of  the 
discharge  of  pus  and  hasten 
the  separation  of  any  remain- 
ing necrotic  tissue.  Without 
doing  any  damage,  attempts 
are  made  to  remove  what- 
ever necrotic  tissue  may  be 

■1  A     1      i.1        1    ,  ™  „  I'lG.  99. — Thio  8amk  Cask   Four  Wkkks  After 

easdy  separated;  the  larger  OrERATioN. 

vessels  are  then  ligated  and 

the  wound  tamponed  with  iodoform  gauze,  which  should  remain  in  posi- 
tion, as  a  rule,  two  days,  until  loosened  spontaneously.  When  the  gauze 
is  removed  granulations  are  already  present,  [^loist  dressings  of  boric 
acid  solution  and  gauze  are  believed  by  some  surgeons  to  be  of  great 
value,  and  if  the  field  of  the  lesion  is  sterilized  l)y  alcohol  at  each  change 
of  the  dressing,  there  is  little  danger  of  spreatling  the  infection.  They 
afford  much  comfort  to  the  patient.) 

Granulation  tissue  fills  in  the  defect  resulting  from  a  large  carbuncle 
in  one  week,  and  becomes  covered  Avith  epithelium  in  from  one  to  two 
weeks  later.  The  scar  then  contracts  (Figs.  97  and  99).  The  inflam- 
mation does  not  subside,  neither  does  the  fever  fall,  when  small,  insuf- 
ficient incisions  are  made. 

When  thrombophlebitis  of  one  of  the  larger  veins  develops,  the  vein 


208  WOUND   INFECTIONS   PRODTTCED   BY   BACTERIA 

should  be  opened,  after  proximal  ligation,  and  the  suppurating  thrombus 
removed. 

Frequently  the  incision  is  postponed  too  long.  In  furuncles  or  car- 
buncles of  the  face  it  is  dangerous  to  delay,  for  here  the  large  number 
of  lymphatics  and  the  frequent  occurrence  of  thrombophlebitis  of  the 
facial  vein  may  lead  to  fatal  results  through  general  infection  or 
meningitis. 

General  infection  is  prevented  by  an  incision  correctly  made  and 
proper  after-treatment,  although  some  believe  that  incision  favors  gen- 
eral infection.  General  infection  may  be  easily  produced  by  curet- 
ting out  the  pus,  squeezing  and  irrigating  the  furuncle,  and  by  any 
other  form  of  mechanical  irritation  {vide  General  Rules  for  Treat- 
ment, p.  199). 

Successful  treatment  is  more  difficult  in  those  eases  in  which  a  num- 
ber of  furuncles  develop  upon  difi^erent  parts  of  the  body  (furunculo- 
sis).  In  these  cases  the  operative  treatment  must  be  combined  with  meas- 
ures which  prevent  the  development  of  virulent  staphylococci.  Daily 
warm  baths  (with  salt  water,  green  soap,  etc.)  should  be  taken,  the  cloth- 
ing should  be  changed  after  each  bath,  new  dressings  applied  to  open 
furuncles  and  those  which  have  developed  opened.  Ointments  and  plas- 
ters favor  the  infection  of  adjacent  areas.  If  the  furunculosis  is  limited 
to  one  part  of  the  body,  one  application  of  a  five  per  cent  formalin  com- 
j:)ress,  which  may  be  allowed  to  remain  for  some  hours,  may  be  of  great 
value. 

It  is  understood  that  diabetics  should  receive  appropriate  internal 
treatment.    In  severe  cases  heart  stimulants  can  rarely  be  dispensed  with. 

THE  SUBCUTANEOUS  ABSCESS 

Any  inflammation  developing  in  the  deeper  tissues  may  lead  to  an 
accumulation  of  pus  in  the  cutis  and  subcutaneous  tissues.  Small  ab- 
scesses following  Avouiuls  are  rarely  limited  to  the  skin;  they  extend  to 
or  develop  in  the  subcutaneous  tissues.  Abscesses  due  to  the  imperfect 
opening  of  a  furuncle  spread  in  this  tissue,  and  circumscribed  suppura- 
tion occun-ing  with  erysipelas,  lymphangitis,  and  subcutaneous  phleg- 
mon (l('V('lo{)s  heie.  All  deep-lying  suppurating  foci  extending  out- 
wai'd  form  collections  of  pus  in  the  meshes  of  the  loose  connective  tissue 
as  soon  as  the  subcutaneous  tissue  is  reached,  as,  for  example,  after  rup- 
ture of  suppurating  foci  of  the  body  cavities,  joints,  bones,  muscles,  and 
all  (]ee])-lying  abscesses. 

If  subcutaneous  ha?matomas  following  injuries^beeome  infected  from 
an  excoriation  or  wound,  an  abscess  is  formed.  Lymphogenous  and 
hematogenous  infections  of  ha^matomas  as  w^ell  as  the  ectogenous  may 


THE  PYOGENIC   INFECTIONS  OF   DIFFERENT  TISSUES 


209 


occur.  Metastatic  abscesses  in  the  subcutaneous  tissues  in  all  parts  of 
the  body,  as  well  as  metastatic  abscesses  of  muscles,  organs,  and  joints, 
may  occur  in  general  pyogenic  infections,  particularly  after  staphylo- 


FiG.  100. — Thk  Interxai.  I.ayp:r  ov  ax  Abscess  Mi;mi;i;ax!;  ('(imposed  of  GRAXtnLATiON 
Tissue.  Newly  formed  capillaries  lie  within  a  cellular  tissue  composed  of  fibroblasts, 
leucocytes,  lymphocytes,  and  fine  fibrillar. 


coeeie  infections.     In  rare  cases  after  typhoid  fever,  the  typhoid  bacilli 
are  the  cause  of  these  general  infections. 


210  WOUND    INFECTIONS   PRODUCED   BY   BACTERIA 

The  subcutaneous  abscess  is  characterized  by  swelling,  redness,  and 
tension  of  the  skin,  pain,  local  elevation  of  temperature,  and  fluctuation 
in  the  center  of  a  hard,  infiltrated  area. 

It  is  accompanied  by  a  moderate,  often  continuous  fever.  The  skin 
covering-  the  center  of  the  abscess  becomes  thin  and  bluish  sooner  or 
later  and  opens  spontaneously  if  not  incised.  After  the  discharge  of 
the  pus  the  inflanniiation  may  subside  and  the  abscess  heal.  The  longer 
the  pus  remains  in  the  tissues,  the  more  extensive  the  granulation  tissue 
which  walls  it  off.  This  abscess  membrane,  composed  externally  of  con- 
nective tissue  bundles,  internally  of  granulation  tissue,  harbors  the  pyo- 
genic bacteria,  which  in  large  cavities  maintain  a  discharge  of  pus  for  a 
long  time  from  the  point  of  rupture  (fistula).  When  the  bacteria  and 
necrotic  tissue  have  been  discharged  in  this  secretion,  the  opposing  walls 
of  the  abscess  grow  together  and  healing  occurs. 

As  a  rule,  abscesses  pursue  a  mild  clinical  course.  If,  however,  the 
encapsulating  membrane  is  ruptured  by  trauma,  massage,  or  movements, 
the  inflammation  may  extend  and  invade  lymphatics  or  blood  vessels. 

Abscesses  heal  rapidly  when  incised  and  subsequently  tamponed  or 
drained.     They  should  never,  however,  be  regarded  too  lightly. 

THE   SUBCUTANEOUS   PHLEGMON 

A  progressive  inflannnation,  which  is  most  often  superficial,  of  the 
subcutaneous  or  of  the  loose  connective  tissues  filling  anatomical  spaces 
(e.  g.,  of  intermuscular  connective  tissue  surrounding  the  oesophagus,  of 
the  mediastinum),  is  called  a  phlegmon. 

If  the  inflammation  is  caused  by  pyogenic  bacteria,  pus  is  formed; 
if  by  putrefactive  bacteria,  there  is  a  tendency  to  gas  formation  and 
gangrene   (vide  Putrid  Inflammation). 

A  phlegmon  of  the  finger  or  toe  is  called  a  panaritium  or  felon. 
Felons  are  classified  as  subepidermal,  subcutaneous,  synovial,  articular, 
and  osteal,  depending  upon  the  tissues  involved.  Phlegmon  of  the  peri- 
osteum is  synonymous  with  suppurative  periostitis,  phlegmon  of  bone 
marrow  with  suppurative  osteomyelitis. 

A  subcutaneous  phlegmon  may  follow  the  pyogenic  infection  of  a 
wound ;  the  infection  may  occur  through  the  blood  stream  in  metastatic 
inflannnation,  or  it  may  extend  from  deeper  tissues.  A  subcutaneous 
phlegmon  may  extend  downward  and  involve  the  fascia  between  the 
niiisclcs,  wlici'c  at)  itijui'v  has  prepai'cd  the  way  for  the  extension  of  the 
i  1 1 1 1 : 1 1 1 1 1 1 1 ;  1 1  i ()  1 1 . 

I'lilcgiiioiis  prrsciil  diCfi  rent  clinical  pictures,  depending  ui)on  whether 
the  serous  or  su])|)uiativ('  type  of  inflamnuition  predominates  and  the 
extent  of  the  necrosis.     One  differentiates  a  serous,  a  suppurative,  and 


THE   PYOGENIC    INFECTIONS   OF    DIFFERENT   TISSUES         211 

necrotic  phlegmon,  but  the  lines  of  separation  are  not  strictly  drawn, 
because  transitions  are  frecjuent. 

The  essential  requirement  in  the  development  of  a  phlegmon  is  a 
bacterial  invasion  of  the  subcutaneous  tissue.  The  cutis  and  the  fascia 
which  limit  the  inflammation  are  only  involved  secondarily.  The  bac- 
teria most  frequently  found  in  phlegmons  are  the  staphylococci  or  strep- 
tococci. Often  both  are  found;  frequently  they  are  associated  with  other 
pyogenic  bacteria. 

Streptococci  produce  the  severest  forms  of  phlegmon,  acting  alone 
or  combined  with  other  bacteria.  They  are  particularly  virulent  when 
they  come  from  a  streptococcic  infection  in  another  individual.  Injuries 
during  post-mortem  examination  of  fresh  cadavers  with  suppurative  peri- 
tonitis, meningitis,  or  general  infections  are  frequently  the  cause  of  the 
most  malignant  forms  of  phlegmon  and  wonnd  infection. 

The  painful  swelling  and  redness  of  the  skin,  associated  with  an  in- 
flammatory oedema  of  the  surrounding  tissues  and  severe  general  symp- 
toms, develop  rapidly.  The  fever,  which,  as  a  rule,  begins  with  a  chill, 
rises  rapidly  and  is  in  the  beginning  continuous.  Later,  when  the  gen- 
eral symptoms  become  pronounced,  there  is  a  decided  morning  remission. 

The  neighboring  lymph  glands  become  swollen  and  painful  early. 
Suppurative  lymphadenitis,  superficial  lymphangitis,  and  thrombophle- 
bitis of  the  subcutaneous  veins  are  often  the  results,  but  also  frequently 
the  cause  of  the  phlegmon.  Bacteria  are  frequently  found  in  the  blood 
when  the  bacteriological  examination  is  correctly  made  (vide  Blood  Ex- 
amination in  General  Infections). 

A  circumscribed  phlegmon  is  differentiated  from  a  diffuse  phlegmon, 
depending  upon  the  local  course  of  the  infection.  The  former  subsides 
even  after  an  acute  onset,  after  a  moderate  extension.  The  virulence  of 
the  bacteria  and  their  toxins  is  reduced  by  the  resistance  of  the  tissues 
and  their  juices.  The  phlegmon  may  run  a  subacute,  often  a  chronic 
course,  and  one  or  several  abscesses  may  form  if  a  wall  of  granulation 
tissue  develops  which  prevents  the  extension  of  the  inflannnation.  Trau- 
ma or  rough  handling  (massage)  may  easily  excite  inflammation  again. 

The  progressive  phlegmon  does  not  subside  vmless  it  is  incised.  It 
pursues  an  acute,  even  violent  course,  and  often  the  subcutaneous  tissue 
of  a  whole  extremity  or  part  of  the  trunk  is  involved,  or  the  infection 
passes  to  the  intermuscular  connective  tissue  and  spreads  incessantly. 

These  differences  in  clinical  course  depend  partly  upon  the  resistance 
of  the  body  and  the  tissues  involved.  The  diffuse  phlegmon  develops 
much  more  frequently  in  the  sick  and  weak  patient  (diabetes,  maras- 
mus) than  in  the  healthy  and  strong,  and  also  in  tissues  which  have 
been  damaged  in  severe  injuries. 

Phlegmons,  especially  those  which  have  been  operated  upon,   fre- 


212  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

queiitly  subside  and  then  develop  again.  After  incision  the  phlegmon 
frequently  ceases  to  spread.  Only  the  severest  forms  cannot  be  con- 
trolled in  this  way.  When  incised  the  cutis  and  subcutaneous  tissue  are 
indurated,  and  large  quantities  of  serous  exudate  are  discharged  from 
the  opened  subcutaneous  tissue.  Onl.y  a  few  small  pockets  of  i)us  are 
found  scattered  throughout  the  tissue. 

The  clinical  course  of  the  suppurative  phlegmon  is  less  malignant 
when  treated  properl3^  In  the  beginning  the  serous  exudate  is  most 
marked,  but  i)us  may  develop  as  early  as  the  second  day.  If  incised  and 
the  pus  is  allowed  to  escape  there  is  but  little  necrosis,  and  it  is  limited 
to  the  subcutaneous  tissues;  the  phlegmon  becomes  limited,  and  the 
inflammatory  swelling  subsides.  If  the  incision  is  delayed  or  is  not  large 
enough,  if  the  phlegmon  is  treated  with  poultices  and  ointments,  the  in- 
flammatory process  destroys  the  fascia,  extends  to  the  spaces  of  the  soft 
tissue,  or  even  to  the  bones  and  joints,  and  gives  rise  not  infrequently  to 
severe  general  symptoms. 

Only  extensive  incision  of  the  phlegmon  will  prevent  the  extension 
of  the  inflammatory  process  and  the  general  infection.  The  incision 
should  be  made — under  general  anaesthesia  and  artificial  ischemia — into 
the  subcutaneous  tissue,  and  should  open  the  pockets  between  the  muscles. 

Counter-openings  should  be  made  to  provide  for  the  discharge  of  pus 
from  the  large  pockets  under  the  separated  skin.  The  fever  falls  rapidly 
after  incisions  which  have  been  properly  made.  The  temperature  may 
rise  again  if  })us  accumulates  in  the  recesses  of  the  wound,  if  the  inflam- 
mation extends,  or  if  the  wound  is  irritated  during  a  change  of  dressings 
{vide  Fundamental  Rules  for  Treatment,  p.  199). 

The  bactei'ia  disappear  from  the  blood,  if  the  inflammatory  processes 
sul)side,  in  from  one  to  two  days  and  the  leucocytosis  disappears. 

The  fii'st  danger  of  a  phlegmon  is  that  the  inflammation  may  extend 
to  important  organs.  A  thrombophlebitis  of  a  subcutaneous  vein  may 
develop  and  the  inflammation  extend  to  the  deeper  tissues  in  this  way. 
IMeningitis  may  follow  a  phlegmon  of  the  face  or  scalp,  mediastinitis  and 
(edema  of  the  glottis  may  follow  a  phlegmon  of  the  neck.  The  second 
danger  is  that  an  infected  thrombus  may  be  loosened  and  that  fatal  lung 
embolism,  lung  abscess,  or  metastatic  infection  may  result.  The  third 
and  gi-eatest  danger  is  general  infection  with  bacteria  and  their  toxins, 
ovei-whelmiug  the  body,  which  can  no  longer  ofifer  resistance.  If  the 
phleginon  is  not  controlled  by  incision  a  fatal  general  infection  may 
develop  unless  an  amputation  is  possible  and  is  performed  at  the  proper 
time  (von  Bergmann,  Ileinr.  Wolfl*).  Severe  symptoms,  extension  of  the 
inflammation,  persistence  of  demonstrable  blood  infection,  decline  of  the 
pnli<-tit  in  spite  of  extensive  incisions  and  free  discharge  of  the  pus  are 
indications  for  this  radical  procedure. 


THE   PYOGENIC    INFECTIONS   OF    DIFFERENT  TISSUES  213 

The  rest  of  the  trealnieiit  is  the  same  as  that  (Mni)l(»yed  Tor  acute, 
suppurative  intlaniiiiation. 

Rest  in  bed  until  the  temperature  reaches  normal  is  necessary.  The 
general  treatment  should  sustain  the  heai't,  which  becomes  weak  in  long- 
continuing  fever,  and  strengthening  nourishment  should  be  given. 

Large  granulating  surfaces,  which  form  in  gaping  wounds  and  after 
the  necrosis  of  large  areas  of  skin,  must  be  skin  grafted  when  in  good 
enough  condition.  Scars  which  produce  contractures  of  the  fingers  or 
joints  may  be  frequently  stretched.  Only  keloid  thickenings  should  be 
excised,  and  then  an  attempt  should  be  made  to  imite  the  edges  of  the 
defect  or  it  may  be  skin  grafted. 

ERYSIPELAS 

Erj'sipelas,  derived  from  ipvOpo'i,  meaning  red,  and  Tre'AXa,  skin,  was 
recognized  by  the  ancients  as  the  most  frequent  wound  infection.  It 
runs  its  course  with  an  acute,  progressive  reddening  of  the  skin  or  nui- 
eous  membrane,  accompanied  by  fever.  It  develops  much  less  frequently 
since  the  introduction  of  antisepsis  and  asepsis. 

Bacteriology  of  Erysipelas. — Fehleisen  (1881)  microscopically,  by  cul- 
tivation (188:3),  demonstrated  that  a  streptococcus  was  the  cause  of  ery- 
sipelas. For  a  long  time  it  was  called  the  streptococcus  of  erysipelas,  and 
distinguished  from  the  streptococci  derived  from  pus,  mucous  membranes, 
and  other  sources.  Clinical  experience,  and  especially  Petruschky's  ex- 
periments and  investigations,  have  shown  that  there  is  no  streptococcus 
which  produces  erysipelas  alone  and  is  specific  for  it  {vide  Streptococcus 
Pyogenes). 

This  explains  wh}^  pus  of  all  kinds,  if  it  gains  access  to  a  wound  of 
the  finger  during  an  operation  or  post-mortem  examination,  may  produce 
erysipelas. 

Often  erysipelas,  without  a  new  infection,  follows  the  incision  of  a 
phlegmon  or  the  aspiration  of  an  empyema  of  a  joint,  for  the  pus  con- 
tains streptococci  which  enter  the  spaces  of  the  cutis  which  have  been 
opened.  The  relation  between  erysipelas  and  puerperal  sepsis  is  ex- 
plained in  this  way.  The  child  of  such  a  patient  develops  an  erysipelas 
of  the  navel,  and  the  physician  who  confined  the  patient  an  erysipelas 
of  an  injured  finger.  The  reverse  may  also  happen ;  the  lying-in  woman 
develops  puerperal  fever  after  being  confined  by  a  midwife  who  has  been 
in  contact  with  erysipelas,  or  who  has  recently  been  sick  with  the  same. 

Explanation  of  Epidemics  of  Erysipelas  in  Hospitals, — It  is  easily  un- 
derstood why  epidemics  of  erysipelas  developed  in  surgical  hospitals  in 
preantiseptic  times,  when  one  considers  the  extensive  distribution  and 
the  resistance  of  streptococci. 
15 


214  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

The  surgeon  and  his  assistants  carried  the  streptococci  from  wound 
to  wound;  their  hands,  the  instruments,  operating  table,  linen,  etc.,  be- 
coming infected  Avith  virulent  streptococci  when  they  incised  an  abscess. 
The  view  that  the  desquamated  skin  contained  streptococci  and  that  in- 
fection occurred  through  the  air  was  disproven  by  Respinger  and  others. 
Erysipelas  is  not  contagious — that  is,  there  is  no  direct  transference  of 
the  disease. 

The  development  of  the  disease  depends  first  upon  a  strain  of  strep- 
tococci,^ which  is  virulent  enough  to  overcome  the  bactericidal  properties 
of  the  tissues  or  becomes  so  after  remaining  in  the  tissues  for  a  short 
time ;  and  secondly,  upon  the  involvement  of  the  lymphatic  spaces  of  the 
cutis  or  mucous  membrane,  after  which,  in  from  one  to  two  days  (accord- 
ing to  Fehleisen  after  fifteen,  at  most  sixty-one  hours,  after  inoculation 
of  man),  the  first  local  symptoms  develop. 

The  invasion  of  the  skin  or  mucous  membrane  may  occur  in  three 
M'ays.  We  distinguish  between  an  ectoyenous,  a  lymphogenous,  and  a 
hcematogenous  erysipelas. 

The  ectogenous  form  is  by  far  the  most  frequent.  There  is  always 
an  epithelial  defect  in  the  skin  or  mucous  membrane  which  provides  the 
infection  atrium.  Rhagades,  ulcers,  insignificant  changes  of  the  skin  and 
mucous  membrane,  old  and  fresh  wounds  are  all  susceptible  to  infec- 
tion. There  are  a  number  of  ways  in  which  the  tissue  spaces  of  old 
wounds  and  ulcers,  which  are  agglutinated  or  closed  by  granulation  tis- 
sue, may  be  opened. 

Erysipelas  is  lympJiogenous  when  the  infection  is  carried  by  the 
Ij^mphatics  from  deeper  inflammatory  foci.  ]\Iost  frequently  it  develops 
fi-oiu  a  streptococcic  lymphangitis  at  some  distance  from  the  infection 
atrium,  and  often  accompanies  or  follows  a  subcutaneous  streptococcic 
phlegmon.  Often  a  subcutaneous  phlegmon  develops  secondarily  to  an 
erysi])ehis.  In  rare  cases  in  which  the  pus  containing  streptococci  ex- 
tends fi-oiM  an  osteal,  articular,  or  glandular  focus  and  penetrates  the 
skin  a  line  rrysijx'las  instead  of  the  indistinct  redness  develops. 

Ifd'tiKitogowus  erysipelas  is  rare.  It  occurs  in  metastatic  strepto- 
coccic infections,  as  a  rule,  associated  with  metastatic  phlegmons,  sup- 
pnrativc  arthritis,  etc. 

Ectogenous  eiysipelas  develops  most  frequently  upon  the  face,  leav- 
ing out  of  considei-ation  the  relatively  rare  wound  erysipelas  which  fol- 
lows operations  and  injuries.  Ila^matogenous  erysipelas  may  develop 
upon  any  part  of  the  body,  while  the  areas  affected  in  lymphogenous 

'  III  ;i  very  few  cases  staphylococci  (Jordan),  typhoid  bacilli  (Rheiner)  and  pnou- 
iiiocoeci  ( Perls- Xcelscn)  have  heen  found  in  uii  inflanunation  of  the  skin  which  re- 
seuihlcd  erysipelas  clinically. 


THE   PYOGENIC    IXFECTIUNS   OF    DIFFERENT   TlSSl'ES  215 

erj^sipelas  depend  upon  the  position  of  the  deep  inflammation.  In 
Rogers's  statistics,  comprising  597  cases,  the  face  was  involved  496,  the 
face  and  scalp  96  times. 

Infection  Atria. — Chaps,  fissures,  rhagades,  eczema,  and  small  wounds, 
particularly  about  the  nose  and  lips,  afford  abundant  opportunity  for 
infection.  Furthermore,  it  is  possible  that  infection  may  develop  from 
the  nasal  secretion  which  contains  streptococci,  or  may  be  produced  by 
contact  and  rubbing  with  soiled  fingers.  Erysipelas  of  the  nnicous  ukmu- 
branes  of  the  nose,  pharynx,  mouth  or  lacrimal  ducts,  and  often  of  the 
auditory  meatus  may  extend  to  the  face. 

Character  of  the  Inflammation,  Clinical  Course,  and  Symptoms. — An 
acute  serous  inflannuation  follows  a  streptococcic  invasion  of  the  cutis. 
The  serous  exudate  sometimes  becomes  purulent.  The  subcutaneous  tis- 
sue is  involved  in  different  degrees.  There  is  a  marked  hypera-mia,  a 
serous  exudate  is  poured  out,  and  the  leucocytes  migrate  into  the  tissue 
spaces.  The  streptococci  multiply  and  spread  in  the  lymphatic  vessels 
and  spaces;  the  lymphatic  vessels  about  the  periphery  of  the  inflamed 
area  being  filled  with  streptococci.  They  are  found  in  the  blood  only  in 
the  htematogenous  form  or  when  a  general  infection  develops.  There 
is  but  little  destruction  of  tissue  in  the  nonsuppurative  erysipelas.  It 
runs  its  course  in  a  few  days  or  a  week,  and  leaves  no  tissue  changes 
other  than  desquamation  and  falling  out  of  the  hair.  The  latter  results 
from  exudation  into  the  hair  follicle.  The  hair  rapidly  grows  again. 
Necrosis  of  the  skin  occurs  only  in  the  severer  forms  or  in  parts  of  the 
body  (over  shin,  patella,  olecranon,  malar  bone,  spines  of  ilium)  where 
there  is  but  little  subcutaneous  fat  and  the  skin  is  not  distensible,  or 
where  the  connective  tissues  are  loose  and  permit  of  a  large  exudation, 
as  in  the  eyelids.  Necrosis  of  the  skin  occurs  more  frequently  in  the 
suppurative,  phlegmonous  forms. 

At  the  beginning  of  an  erysipelas  the  areas  of  skin  involved  are  red- 
dened, hot,  indurated,  and  painful  upon  pressure  and  contact.  The 
patient  complains  of  a  burning  or  stinging  pain.  A  chill  and  high  fever 
precede  or  accompany  these  local  changes.  In  a  few  hours  a  sharply 
delimited  redness  and  swelling  of  the  skin  develops.  The  rapidly  ex- 
tending borders  of  the  swelling  follow,  according  to  Pfleger,  the  parallel 
linear  furrows  and  connective  tissue  bundles  of  the  corium,  mostly  in 
the  direction  of  the  lymph  stream,  but  also  against  it.  It  sends  out  deep 
red,  curved  offshoots,  flamelike  tongues  and  points,  between  which  lie 
pale  areas  of  skin  which  were  first  affected.  The  inflammation  rarely 
extends  symmetrically,  but  more  frequently  fi'om  this  and  now  from 
that  border,  just  as  the  troops  are  thrown  into  a  breach  when  storming 
a  fortress.  The  inflammation  may  extend  slowly  or  so  rapidly  that  in 
a  single  night  the  entire  face  may  be  involved.     Often  the  erysipelas 


21G  WOUND    INFECTIONS   PRODUCED   BY   BACTERIA 

comes  to  a  standstill  in  regions  where  the  skin  is  firmly  attached  (e.  g., 
to  the  crest  of  the  ilinm).  Often  large  areas  of  skin  are  uninvolved  and 
completely  snrronnded  by  the  inflannnation,  so  that  they  appear  as 
white  islands  snrronnded  by  reddened,  erysipelatous  skin.  A  marked 
oedema  develops  in  erysipelas  of  the  eyelids  and  external  genitalia,  as 
the  underlying  connective  tissue  is  very  loose. 

Clinical  Forms  of  Erysipelas. — The  clinical  forms  which  have  been 
described  frequently  pass  over  into  each  other.  Erysipelas  erythema- 
tosum  is  characterized  by  the  marked  redness  of  the  skin,  erysipelas 
bullosum  by  vesicles,  erysipelas  pustulosum  by  pustules,  erysipelas 
phlegmonosnm  by  subcutaneous  suppuration,  erysipelas  necroticum  (gan- 
gra'nosum)  by  necrosis  of  the  skin.  It  is  simpler,  however,  to  speak  of  a 
suppurative  and  nonsuppurative  form,  for  suppuration  means,  as  a  rule, 
not  only  a  local,  but  also  usually  a  general  aggravation.  With  the  ex- 
tensive destruction  of  skin  and  subcutaneous  tissues,  as  in  severe  phleg- 
mons, there  come  the  dangers  of  metastatic  infection,  favored  by  throm- 
bophlebitis, and  of  general  infections. 

Erysipelas,  as  a  rule,  runs  its  course  in  from  six  to  ten  days.  Its 
duration  varies  between  hours  and  weeks.  An  erysipelas  of  the  extremi- 
ties, occurring  with  a  lymphangitis,  which  is  the  most  marked  feature 
of  the  clinical  picture,  may  disappear  in  a  day.  Erysipelas  of  the  face 
and  scalp  does  not,  as  a  rule,  last  longer  than  a  week.  Only  the  rarer 
forms  which  migrate  from  the  face,  scalp,  or  extremities  to  the  breast 
and  back,  and  erysipelas  of  the  trunk,  last  longer.  There  are  cases  of 
erysipelas  in  which  the  infiannnation  extends  almost  over  the  entire  body, 
recurs  in  areas  which  have  been  healed  for  some  time,  persists  for  weeks, 
and  exhausts  the  patient. 

lieciirrent  and  Ilahitual  Erysipelas. — A  recurrence  of  erysipelas,  by 
which  is  understood  a  new  infection  and  not  a  relapse  occurring  in  the 
course  of  an  existing  inflammation,  occurs  where  an  open  wound  affords 
an  infection  atrium.  Such  infection  atria  are  afforded  by  tuberculous 
fistula,  ulcers  of  all  sorts  (syphilitic,  carcinomatous,  and  varicose),  rha- 
gades  and  chronic  eczema.  An  attack  of  erysipelas  never  affords  an 
imnnmity.  Streptococci,  although  of  lessened  virulence,  which  persist 
in  such  ulcers,  invade  the  tissues  again  as  soon  as  a  mechanical  irritation 
opens  the  lymphatic  spaces  of  the  cutis.  Many  individuals  are  subject 
to  what  is  described  as  habitual  erysipelas,  which  involves  most  fre- 
(Hicntly  the  face.  In  these  cases  the  slightest  irritation,  such  as  sneezing 
or  wiping  the  nose,  may  provoke  an  attack.  These  individuals  have  ap- 
pJiiciitly  but  jitlle  I'csistance  against  streptococci. 

Involvement  of  Lijmpli  Nodes,  Ahsc(ss  Fonnalion,  I'lilchllis,  etc. — 
Tfcdness  and  swelling  of  the  skin  arc  not  the  only  symptoms  of  erysipelas. 
The   ncigliboring  lymphatic  glands  become  painful   and  swollen  early, 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT  TISSUES  217 

and  in  erysipelas  oF  the  cxlrcniitics  there  is  i'i'e((ueiit]y  an  aceoiiipatiyiivi,' 
lymphangitis.  Both  usually  subside  without  su|)puration.  Abseess  for- 
mation is  the  exception. 

Abscesses  occur  only  in  the  suppurative  form  of  erysipehis,  and,  as  a 
rule,  are  produced  by  secondary  infection  with  staphylococci.  Phh'bitis 
occurs  especially  in  erysipelas  of  the  legs.  Thrombi  then  form  which 
may  suppurate  if  the  vein  wall  is  penetrated  by  cocci,  and  metastatic  in- 
flammation may  develop  as  a  consequence.  Besides,  there  are  general 
symptoms,  different  complications,  and  sequeloe. 

Onset  and  Clinical  Course. — The  disease  and  the  general  reaction  be- 
gin, as  a  rule,  with  a  severe  chill  and  fever.  Frequently  the  tempera- 
ture reaches  103°  or  104°  F.  If  the  erysipelas  extends,  a  continuous  fever 
persists  during  its  course,  which  falls  by  crisis  or  lysis  as  the  inflam- 
mation approaches  its  termination.  The  fever  is  intermittent  or  remit- 
tent when  the  inflammation  extends  at  irregular  intervals  (vide  Fever, 
J).  16-4).  The  other  symptoms  of  fever — rapid  pulse,  gastric  and  p.sychie 
disturbances,  headache,  restlessness,  stupor,  delirium — are  frequently 
present  in  different  degrees.  For  the  most  part  these  symptoms  as  well 
as  the  temperature  are  the  result  of  the  absorption  of  bacterial  toxins. 
In  erysipelas  of  the  head  and  face  the  cerebral  symptoms  are  frequently 
pronounced.  They  may  pass  into  the  symptoms  of  meningitis  or  may 
lead  to  the  diagnosis  of  this  complication.  Fortunately  meningitis  fol- 
lows but  rarely  erysipelas  of  the  scalp  and  the  secondary  orbital  phleg- 
mon, by  extension  of  a  thrombophlebitis.  In  rare  cases  erysipelas  nuis 
its  course  without  fever. 

Bacteria  but  Rarely  Found  in  the  Blood  in  this  Disease. — Streptococci 
are  but  rarely  found  in  the  blood  (Pfuhl,  von  Noorden,  Ileitz,  and 
Widal).  Apparently  they  are  retained  in  the  lym])hatie  glands  for  the 
most  part.  The  streptococci  which  do  pass  into  the  blood  are  rapidly 
destroyed.  Even  after  death  bacteria  are  not  fre(iuently  found  in  the 
blood.  Only  in  the  severer  forms  of  erysipelas  and  in  those  forms  asso- 
ciated with  metastatic  inflannnation  are  they  found  in  the  blood  in  large 
numbers. 

Sometimes  other  bacteria  besides  the  strept(^coeci  are  found  in  the 
metastatic  foci.  These  gain  entrance  through  rui)tured  vesicles  and  ne- 
crotic cutaneous  areas.  Zeller  and  Arnold  liave  found,  for  instance,  a 
long,  gas-producing  bacillus. 

Complications. — The  complications  of  erysipelas  result  from  an  ex- 
tension of  the  inflammation  and  from  the  development  of  metastatic 
infections.  The  inflammation  may  extend  and  produce  a  suppurative 
inflammation  of  the  parotid  gland,  tendon  sheaths,  bui'sa\  nmseles,  and 
joints.  A  phlegmon  of  the  orbital  fat  may  develop  and  cause  secondai-y 
suppuration  of  the  bulb  or  meningitis.    An  acute  inflannnatorj'-  laryngeal 


218  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

stenosis  may  follow  the  extension  of  a  pliaiyngeal  erysipelas  to  the 
larynx.  This  may  extend  and  involve  the  lungs,  which  may  also  be 
infected  through  the  blood  stream.  Pleurisy,  which  is  rare,  develops 
from  foci  in  the  lungs,  or  as  a  metastatic  infection ;  endocarditis  is  rare. 

Cardiac  weakness,  which  may  persist  for  a  long  time,  is  the  most 
important  of  the  sequelae.  It  must  be  attributed  to  the  action  of  the 
streptococcic  toxins,  although  myocarditis  is  rare.  The  acute  nephritis 
lasts  but  a  short  time,  and  only  in  cas6  of  preexisting  nephritis  does  it 
pursue  a  severe,  occasionally  a  fatal  course.  Frequently  a  recurring 
erysipelas  produces  a  chronic  irritation  of  the  skin  which  excites  connec- 
tive tissue  growth.  The  lymphatics  become  occluded,  and  a  lymphstasis 
or  lymphatic  oedema  results  (pachydermia  of  the  face,  Friedrich,  Bern- 
hardt, elephantiasis  of  the  extremities  and  external  genitalia). 

Prognosis. — The  prognosis  is  most  favorable  in  the  usual  nonsuppura- 
tive erysipelas  of  the  face  and  head,  less  so  in  erysipelas  of  the  trunk, 
because  of  its  longer  course.  In  the  suppurative  forms  general  and 
metastatic  infections  develop  most  frequently. 

Erysipelas  in  alcoholics,  in  patients  weakened  by  previous  disease, 
and  in  the  newborn  gives  the  most  unfavorable  prognosis. 

Next  to  the  cardiac  weakness,  pneumonia  and  meningitis  are  the  most 
frequent  causes  of  death,  which,  according  to  Zuelzer's  statistics,  com- 
prising 10,000  cases,  occurs  in  eleven  per  cent  of  the  cases. 

Diagnosis. — The  diagnosis  of  erysipelas  is,  as  a  rule,  easily  made. 
The  progressive  and  sharply  limited  redness  and  swelling  of  the  skin 
and  the  high  fever,  which  begins  with  a  chill,  are  so  characteristic  that 
there  can  be  but  little  doubt  as  to  the  diagnosis.  The  scalp  shows  but 
little  redness,  but  the  extension  of  the  disease  and  the  pain  elicited  by 
pressure  indicate  the  nature  of  the  intianniiatory  process. 

Treatment. — The  methods  of  the  treatment,  which  are  intended  to 
control  tlie  disease,  are  as  numerous  as  they  are  useless.  There  is  no 
agent  v/hicli  will  arrest  the  inflammation.  Serum  therapy  has  as  yet 
been  unsuccessful  {vide  Streptococci).  Attempts  to  limit  the  extension 
of  the  inflammation  by  closing  the  lyinphatic  channels  (cauterization  of 
surrounding  healthy  skin,  ai)i)lication  of  adhesive  strips,  collodion,  and 
other  agents)  are  unsuccessful,  for  the  streptococci  then  seek  the  deeper 
lyinphntifts.  Antiseptics,  which  luive  been  injected  into  the  inflamed 
aieji  nnd  into  the  healthy  surrounding  area,  do  not  prevent  the  extension 
of  llie  inllaiiiiiuilion.  Just  as  little  is  to  be  expected  from  the  use  of 
jinliseptic  compresses,  applied  with  or  without  ])i-evious  incision  or  scari- 
fication of  the  infhuned  ar»>a  and  of  antisejjtic  ointments.  The  ice  bag 
jiiid  cold  compresses  should  not  be  used,  because  of  the  danger  of  necrosis 
of  tile  skin;  multiple  punetui-es  are  indicated  to  i)revent  the  latter  where 
the  (I'dema  is  mai-ked   (eyelids). 


THE   PYOGENIC   INFECTIONS  OF   DIFFERENT  TISSUES         219 

The  main  object  of  the  treatment  should  be  to  control  the  pain  and 
prevent  harm  (secondary  infection,  mechanical  irritation).  INIoist  com- 
presses and  ointments  lessen  the  pain.  The  former,  however,  almost  in- 
variably produce  an  eczema  which  provides  new  infection  atria ;  non- 
irritating  ointment  dressings  of  vaseline  and  zinc  oxid  are  therefore  most 
useful.  Gauze  masks  may  be  made  for  the  face.  The  extremities  should 
be  immobilized  by  splints  and  elevated  after  application  of  the  ointment 
dressings.  It  is  understood  that  the  patient  should  remain  in  bed.  The 
suppurative  forms  of  erysipelas  should  be  treated  according  to  the 
general  principles  already  described  {vide  p.  197). 

In  habitual  erysipelas  a  special  treatment  is  demanded  for  the  ulcers 
w'hich  afford  the  infection  atria.  Eczema  should  be  treated  with  oint- 
ments, tuberculous  ulcers  by  cauterization,  other  ulcers  with  suitable 
dressings,  etc. 

General  treatment  should  combat  the  cardiac  weakness.  Nutritious 
food,  wine,  and  injections  of  camphor  should  be  given. 

The  method  of  treatment  of  wounds  employed  at  the  present  time  is 
the  best  prophylaxis.  Streptococci  are  rarely  found  in  the  erysipelatous 
blebs  (Respinger),  so  there  is  no  more  danger  of  contagion  than  in  other 
suppurative  infections.  The  disease  follows  the  transference  of  the  secre- 
tion containing  streptococci  to  the  infection  atrium.  For  this  reason 
patients  with  erysipelas  should  be  placed  in  the  isolation  ward  with 
patients  suffering  from  acute  suppurative  inflammation  {vide  General 
Rules  for  Treatment  of  Suppurative  Inflammation). 

The  therapeutic  action  of  erysipelas  upon  malignant  tumors  and 
syphilitic  and  tuberculous  granulation  growths  has  attracted  consider- 
able attention  lately.  Busch  (186C)  demonstrated  this  action  upon  a  sar- 
coma of  the  skin.  The  tumor  became  hypera^nic,  underwent  a  rapid 
fatty  degeneration,  and  disappeared  by  absorption  following  an  attack 
of  erysipelas.  Clinical  experience  and  the  infection  of  patients  suffering 
from  inoperable  tumors  have  demonstrated  that  the  results  are  not  sure 
and  constant  (Fehleisen,  P.  von  Bruns;  cf.  also  Tuberculosis,  Part  111). 

[The  mixed  toxins  of  erysipelas  and  prodigiosus  of  Coley  have  been 
employed  with  curative  effect  in  a  small  proportion  of  inoperable  sar- 
comas.] 

Literature. — M.  Bernhordt.  Pachydennie  bei  habituellem  Gcsichtserjvsipcl. 
Miinch.  med.  Wochenschr.,  18!)7,  p.  887. — P.  Bruns.  Die  Heihvirkung  des  Erysipels 
auf  Geschwiilste.  Beitr.  z.  klin.  Chir.,  Bd.  3,  1888,  p.  443. — W.  Busch.  Einfluss  von 
Erysipel  auf  organische  Neubiklungon.  Berl.  klin.  Wochenschr.,  18(50,  p.  245. — Fehleisen. 
Untersnchungen  iibor  Erysipel.  Verhandkingcn  dcr  Wiirzb.  phys.  nie<l.  Gesellsch. 
Sitzungsberichte,  August,  1881,  p.  126; — Das  Erysipel.  Deutsche  Zeifschr.  f.  Chir., 
Bd.  16,  1882,  p.  391; — Die  Aetiologie  des  Erysipels.  Berlin.  1883.— /•V«H^-<'.  Ein 
Beitrag  zur  Frage  der  Kontagiositiit  des  l'>ysipels.  Deutsche  Zeitschr.  f.  Chir.,  Bd. 
78,    1905,   p.    182. — Friedrkh.     Pachydennie   ini   Anschluss   an   habit uellcs   Gesichts- 


220  WOUND   INFECTIONS  PRODUCED   BY   BACTERIA 

erysipel.  Miinch.  med.  Wochenschr.,  1897,  p.  33. — Jordan.  Ueber  die  Aetiologie 
des  Erysipels  u.  s.  w.  Miinch.  med.  Wochenschr.,  1901,  p.  1371. — Klemm.  Ueber  das 
VerhaUnis  des  Erysipels  zu  den  Strei^tomykosen.  Mitteil.  aus  den  Grenzgeb.,  Bd.  8. — 
Koster.  Behandkuig  des  Erysipels  mit  Vaseline.  Therapeiit.  Monatshefte,  1896. — • 
Lcnhartz.  Erysipelas  und  Erysipeloid.  In  Nothnagels  spez.  Path.  u.  Ther.  Wien, 
1899. — V.  Noorden.  Ueber  das  Voikonunen  von  Streptokokken  im  Blute  bei  Ery- 
sipelas. Miinch.  med.  Wochenschr.,  1887. — Pfuhl.  Ein  Fall  von  Allgemeininfektion 
mit  Streptokokken  infolge  Hauterysipel.  Zeitschr.  f.  Hygiene  und  Infektionskrank- 
heiten,  Bd.  12,  1892,  p.  517. — Respinger.  Untersuchungen  iiber  die  angebliche 
Kontagiositat  des  Erysipels.  Beitr.  z.  klin.  Chir.,  Bd.  30,  1901,  p.  261. — Tillmanns. 
Erysipelas.     Deutsche  Chir. 

ERYSIPELOID 

There  is  a  disease,  the  local  symptoms  of  which  resemble  closely  those 
of  erysipelas.  It  was  known  earlier  as  chronic  erysipelas,  erythema  mi- 
grans, and  Avas  called  erysipeloid  ^  by  Rosenbach.  It  develops  most  fre- 
quently from  small  wounds  of  the  fingers,  but  is  occasionally  seen  upon 
the  nose,  cheeks,  and  neck. 

Onset  and  Clinical  Course. — It  begins  with  a  mild  burning  and  itch- 
ing of  the  skin  without  fever  or  any  general  reaction.  The  skin  becomes 
somewhat  swollen,  painful,  and  discolored  a  deep  bluish  red.  It  extends 
slowly  from  the  infection  atrium,  the  older  area  becoming  pale,  toward 
the  hand,  from  the  base  of  a  finger  to  the  neighboring  finger,  but  rarely 
as  high  as  the  middle  of  the  hand.  A  lymphangitis  of  the  arm  which 
resists  treatment  is  seen  in  ten  per  cent  of  the  cases. 

The  disease  lasts  usually  one  week.  Many  cases,  however,  namely, 
those  which  have  not  been  treated,  persist  for  three  or  four  weeks. 

Erysipeloid  has  some  relation  to  dead,  decomposing  animal  matter. 
It  attacks  frequently  cooks,  butchers,  tanners,  fishmongers,  men  who  open 
oysters,  and  merchants  who  come  in  contact  with  cheese  or  herring. 
Almost  always  some  wound  can  be  demonstrated  which  affords  the  infec- 
tion atrium. 

Organism  Found  in  Erysipeloid. — A  cladothrix-like  micro-organism 
was  obtained  in  purt'  cultures  from  a  diseased  area  of  skin  by  Rosenbach 
(1887)  ;  inoculation  of  a  cutaneous  wound  with  this  micro-organism 
caused  erysipeloid.  The  findings  have  been  confirmed  by  the  researches 
of  Ohlemann  (1904).  It  is  difficult  to  classify  this  irregularly  round 
mici-obc,  which  develops  into  threads  in  old  cultures. 

Diagnosis. — It  is  impossible  to  mistake  the  disease  when  fully  devel- 
oped.    Erysipelas  extends  more  rapidly   and   is  almost  always   accom- 


'  'i'lic  autlK)r  cannot  accept  the  case  reported  by  Tavel,  which  presented  fever,  gen- 
eral niiictioii  and  severe  local  symptoms,  as  one  of  pure  erysipeloid.  He  sees  yearly 
30  to  H)  cases  f)f  erysii)eloi(l  among  the  10  to  20,000  paticTits  treated  at  the  Royal  Poly- 
clinic a(   licrlin.      Apparently  thi.s  case  was  one  complicated  by  a  ])yogenic  infection. 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT   TISSUES  221 

panied  by  fevor.  The  redness  associated  with  lyniphaiifiitis  reticularis 
occurring  upon  the  fingers  has  indistinct,  never  sharply  defined  boun- 
daries. 

Treatment. — The  best  and  simplest  treatment  consists  of  innnobili/a- 
tion  (papier  mache  splint)  of  the  fingers,  to  which  vaseline  has  been 
applied,  for  two  or  three  days.  The  redness  rapidly  fades,  but  if  move- 
ments are  made  too  early  it  recurs  again  in  some  areas.  Resistant  cases 
are  rare. 

Literature. — Cordua.  Zur  Aetiologie  des  Erythema  multiforme.  Deutsche  med. 
Wochenschr.,  1885. — Delbanco.  Ueber  das  Erysipeloid.  Deutsche  Medizinalzeitung, 
1898,  No.  78. — Gilchrist.  Erysipeloid  (329  Falle).  Journ.  of  Cutaneous  Diseases,  1904, 
November. — ■Ohlemann.  Beitr.  z.  Kenntnis  des  Erysipeloids  und  dessen  Aetiologie. 
I.-D.  Gottingen,  1904. — Rosenbach.  Ueber  das  Erj^sipeloid.  Chir.-Kongr.  VerhantU., 
1887,  II,  p.  lo.—Tavel.  Das  Erysipeloid.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  61,  1901, 
p.  528. 

(b)     THE   PYOGENIC   INFECTIONS   OF   MUCOUS   MEMBRANES 

The  rich  bacterial  flora  of  the  mucous  membrane,  which  comprises 
not  only  harmless  bacteria  but  pyogenic  and  putrefactive  bacteria  as 
well,  may  be  easily  increased  during  respiration  or  the  taking  of  food. 
For  this  reason  in  many  inflammations  of  mucous  membranes  mixed  and 
secondary  infections  occur. 

The  pyogenic  infections  can,  in  spite  of  the  many  transitions,  be  dif- 
ferentiated from  the  putrefactive  forms,  in  which  putrefactive  bacteria 
are  the  deciding  factors. 

Infection  Atria. — Small  injuries  and  large  wounds,  changes  produced 
by  diseases  (diphtheria,  gonorrhea,  syphilis,  tuberculosis,  typhoid  ulcers, 
cauterization,  thrush,  and  ulcers  due  to  dentition),  or  the  anatomical  re- 
lations of  the  mucous  membranes  covering  lymphatic  structures  afford 
the  infection  atria.  A  lymphogenous  inflannnation  develops  when  the 
infection  travels  through  the  lymphatics  from  a  neighboring  focus;  a 
ha^matogenous  inflamnuition  may  occur  in  general  pyogenic  infections, 
as  a  result  of  which  small  embolic  abscesses  may  develop  in  the  intestinal 
and  gastric  mucous  membrane. 

In  certain  diseases  of  the  mucous  membrane  of  the  mouth  cavity, 
w^hich  occur  in  chronic  poisoning  wdth  mercury,  phosphorus,  lead,  and 
arsenic,  and  begin  with  inflammatory  swelling  and  exfoliation  of  the 
mucous  membrane,  the  bacteria  of  the  mouth  cavity  are  able  to  invade 
the  tissues,  as  their  resistance  is  greatly  reduced.  In  this  way  the  bac- 
teria participate  secondarily  in  the  severe  ulcerating  forms  of  inflamma- 
tion associated  with  necrosis  or.  gangrene. 

Varieties. — The  pyogenic  bacteria  foiuid  mo.st  frequently  in  inflam- 
mation of  the  nnicous  membrane  are  the  staphylococcus,  streptococcus. 


222  WOUND    INFECTIONS   PRODUCED   BY    BACTERIA 

gonoeocciis,  pneuniococcus,  bacterium  coli  commune;  to  these  may  be 
added  the  bacilli  of  pneumonia  and  influenza. 

The  superficial  inflammations  of  mucous  membranes  produce  a  serous 
or  suppurative  catarrh  (from  Karappew, to  flow)  or  a  fibrinous  membrane 
(croupous  inflammation).  The  mucous  membrane  becomes  markedly 
hyperffimic  and  oedematous;  in  the  larynx  this  oedema  may  be  great 
enough  to  produce  a  dangerous  stenosis. 

A  serous,  purulent,  or  purulo-ha?morrhagie  exudate  is  then  discharged 
upon  the  surface  of  the  mucous  membrane,  the  normal  mucous  secretion 
of  which  is  altered.  Often  in  the  mouth  and  pharynx  vesicles  are  formed 
with  resulting  exfoliation  of  the  superficial  epithelial  layers  (desquam- 
ative catarrh),  and  superficial  ulcers  (catarrhal  ulcers)  which  heal  by 
granulation  tissue  form.  The  lymphoid  organs  are  always  enlarged  and 
may  suppurate  (tonsillar  abscess,  follicular  abscess,  intestinal  ulcer). 

A  fibrinous  membrane  is  formed  by  the  coagulation  of  the  exudate, 
where  the  connective  tissues  are  exposed  after  the  destruction  of  the 
epithelium  by  inflammation  or  injury.  The  whitish  yellow  (if  mixed  with 
blood,  brown)  more  or  less  firmly  attached  membrane  shows  a  marked 
contrast  to  the  reddened  surrounding  tissue.  It  resembles  the  pseudo- 
membrane  of  diphtheria,  but  the  fibrinous  network  and  necrosis  of  tissue 
never  extends  so  deeply  in  croupous  inflammation.  This  fibrinous  (croup- 
ous) inflammation  which  occurs  in  the  upper  air  passages  in  a  number  of 
diseases  (measles,  scarlet  fever,  whooping  cough,  pneumonia,  typhoid 
fever,  etc.),  and  in  which  pyogenic  bacteria  participate  (streptococci), 
is  called  diphtheroid  to  differentiate  it  from  the  inflannnation  produced 
by  the  bacillus  of  diphtheria.  Similar  fibrinous  inflannnations  occur  in 
the  bladder,  vagina,  and  intestine.  Frequently  they  become  secondarily 
infected  with  ])utrefactive  bacteria  and  then  gangrenous  ulcers  develop. 
Small,  roui'd,  painful,  yellowish  areas,  surrounded  by  a  red  zone,  are 
produced  l)y  this  fibrinous  inflammation  associated  with  necrosis  of  the 
epithelium.    These  occur  frequently  in  the  mouth  and  are  called  aphthae. 

Deep  infiammations  of  mucous  membranes  develop  from  wounds, 
about  penetrating  foreign  bodies,  or  extend  from  the  inflamed  surface 
of  the  membrane. 

They  produce  a  marked  inflannnatory  oedema  and  a  phlegmon  of  the 
suhiiiucous  lissups.  The  surface  of  the  nuicous  riiembrane  is  involved 
in  (liCI'ci'ciit  degrees;  it  may  i)resent  only  a  catarrhal  inflammation,  or 
may  be(;oiiie  necrotic. 

J*us  colleels  in  bony  cavities  lined  by  nuieous  membrane,  in  hollow 
organs  such  as  llie  g;ill  bladder  and  a])pendix  when  the  outl(»t  is  occluded 
by  inflannnatory  swelling  of  the  nnicous  membrane  or  by  other  causes 
(e.  g.,  sn|)|)nrative  otitis  media,  empyema  of  tlie  gall  bladder,  and  pro- 
cessus vermiroi-niis).     If  secondaiy  infection  with  putrefactive  bacteria, 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT  TISSUES  223 

which  waiulci-  in  from  the  iiKHith  oi'  intestiiic,  occurs  tlic  pus  becomes 
foul  smelling  and  the  mucous  membrane  becomes  gangrenous. 

Erysipelas  of  the  mucous  membrane  is  an  acute  inflanunation  of  the 
surface  membrane,  combined,  however,  with  a  sul)mucous  and  a  deeper 
phlegmon.  An  accurate  diagnosis  can  only  be  made  when  the  inflam- 
mation extends  to  the  skin,  although  it  may  be  suspected  because  of  its 
violent  course  with  high  fever  and  severe  general  sym])toms.  It  occurs 
in  the  pharynx,  nose,  larynx,  and  upon  the  female  genitalia,  and  recurs 
frequently  where  a  chronic  inflammation  of  the  mucous  membrane  favors 
the  growth  and  invasion  of  the  streptococci. 

Results  of  Inflammation. — The  results  of  inflannnation  of  mucous 
membranes  ditfer.  Catarrhal  inflannnation  and  sui)erfleial  ulcers  heal 
by  absorption  of  the  inflannnatory  exudate  and  proliferation  of  the  epi- 
thelium, leaving  no  trace  of  the  inflammation.  A  scar  is  found  when 
a  deep  ulcer  heals.  Incomplete  repair  or  the  frequent  recui-rence  of 
mild  inflammation  produces  a  chronic  inflammatory  condition  which  re- 
sults either  in  thickening  and  induration  with  glandular  hypertrophy  and 
growth  of  the  lymphoid  tissue  or  atrophy  of  the  mucous  membrane. 

Fever  and  general  symptoms  usually  accompany  the  acute  inflamma- 
tions of  nnicous  membranes.  They  may  even  be  present  in  a  very  mild 
angina  or  enteritis.  Their  duration  depends  entirely  upon  the  course  of 
the  local  inflammation. 

The  extension  of  these  pyogenic  infections  from  the  upper  air  pas- 
sages to  the  lung,  and  the  dift'erent  infections  of  the  mucous  membrane 
of  the  gastrointestinal  tract  are  of  much  less  importance  to  the  surgeon 
than  the  suppurative  phlegmonous  forms  of  inflannnation,  the  second- 
ary diseases  of  the  lymphatic  glands,  and  the  general  infections  with 
bacteria. 

The  phlegmon  of  the  mucous  membrane  carries  witli  it  many  dangers. 
A  suppurative  inflammation  of  the  floor  of  the  mouth  develops  from  a 
phlegmonous  glossitis  or  suppurative  periodontitis.  It  is  accompanied  by 
a  marked  infiltration  of  the  tissues,  extends  between  the  nuiscle  ]ilanes 
of  the  neck,  and  may  cause  an  oedema  of  the  glottis  or  a  nu'diastinitis, 
which  proves  fatal. 

A  phlegmon  may  spread  under  the  nnieous  nicinbi-ane  of  the  mandible 
or  cheek  and  produce  a  meningitis  unless  controlled.  The  tissue  of  the 
tonsil  is  frequently  the  seat  of  small  abscesses,  which  develop  from  the 
crypts,  and  the  origin  of  phlegmons  which  extend  to  the  peritonsillar 
tissues  and  soft  palate.  Phlegmons  developing  in  the  pharynx  or  ipsoph- 
agus  may  gravitate  in  the  loose  tissues  surrounding  these  structures  to 
the  mediastinum.  Abscesses  of  the  intestinal  wall  and  submucous  phleg- 
mons of  the  pylorus  may  rupture  into  the  free  jx-ritoneal  cavity  and  pro- 
duce a  suppurative  peritonitis;  this  occurs  most  frecpiently  in  the  ap- 


224  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

peiidix.  Abscesses  of  Ihc  l)];i(ldei'  may  ruptui-e  extei-iially  and  produce 
perivesiciilar  suppuration,  phlegmons  of  the  urethral  mucous  membrane 
(by  ulceration,  injury  during  catheterization)  may  spread  to  the  scrotum 
and  perineum.  Periprocteal  abscesses  develop  in  the  tissue  surrounding 
the  rectum.  These  rupture  externally  and  leave  frequently  the  resistant 
fistula*  in  ano.  Where  the  submucous  tissues  are  closely  connected  with 
bone,  suppurative  periostitis,  osteomyelitis,  and  necrosis  develop  second- 
ary to  the  phlegmon. 

An  inflammatory  enlargement  of  the  neighboring  lymphatic  nodes 
follows  inflannnation  of  a  mucous  membrane.  The  acute  lymphadenitis 
occurring  in  the  neck  (submaxillar}'  region  in  angina)  is  a  well-known 
and  striking  example. 

The  glandular  enlargement  disappears  as  the  inflammation  subsides. 
This  enlargement  persists  if  the  inflammation  recurs  frequently  or  if 
there  is  a  chronic  inflammation  of  the  mucous  membrane.  In  such  cases 
chronic  irritation  leads  to  a  hyperplasia  of  the  glandular  tissue.  The 
glands  suppurate  only  in  the  more  severe  forms  of  suppurative  catarrh, 
in  phlegmons  and  erysipelas  of  the  nuicous  membrane. 

The  absorption  of  very  virulent  bacteria  from  diseased  mucous  mem- 
branes gives  rise  to  metastatic  inflammation  or  general  infection.  This 
may  occur  in  superficial  as  well  as  in  deep  inflammations.  It  is  well 
known  that  malignant  and  fatal  general  infections  are  produced  by  the 
streptococci,  which  enter  the  circulation  from  catarrhal,  phlegmonous, 
and  putrefactive  inflaunnations  of  mucous  membranes.  In  rare  cases  the 
colon  bacillus  may  enter  the  blood  during  an  enteritis.  Metastatic  in- 
flanniiations  occur  nuich  more  frequently  than  the  general  infections. 
Streptococcic,  staphylococcic,  pneumococcic,  and  other  infections  may  de- 
velof)  after  an  acute  angina  ;  inflannnation  of  the  accessory  sinuses  of  the 
nose  stands  in  intimate  relation  to  supjun-ative  arthritis,  muscle  abscess, 
metastalic  phlegmon,  and  osteomyelitis. 

Treatment. — No  agent  or  measure  should  be  employed  in  the  treat- 
mcnl  of  j)y()g('iiic  inflammations  of  mucous  membranes  which  favor  the 
absoi'ption  of  bacteria.  Mechanical  irritation,  such  as  painting  the 
pharynx,  ii'i-igating  the  nose,  antrum  of  Ilighmore,  the  urethra,  etc.,  Avip- 
ing,  tearing,  or  curetting  away  the  fibrinous  (croupous)  membrane,  for- 
merly extensively  employed,  does  this. 

Antiseptics  do  not  retard  the  development  of  the  bacteria  imbedded 
in  the  nuicous  secretion,  neither  do  they  destroy  those  hidden  in  the  folds 
and  pockets  of  the  mucous  membrane. 

On  the  other  hand,  if  too  strong  they  irritate  the  mucous  membrane, 
destroy  the  surface  epithelium,  and  in  this  way  provide  new  infection 
atria.  Besides,  in  washing  the  mouth  small  amounts  of  these  antiseptics 
(e.  g.,  potassium  chlorate)  may  be  swallowed  and  do  harm. 


THE   PYOGENIC    INFECTIONS   OF    DIFFERENT   TISSUES  225 

The  most  important  thing'  in  the  treatment  of  acute  inflannnations  of 
mucous  membranes  is  to  remove  mechanically  the  bacteria  contained  in 
the  secretion  or  resting  up  the  surface  of  the  mucous  membrane.  This  is 
done  by  frequently  washing  (depending  upon  location,  by  gargles,  mouth 
Avashes,  weak  irrigation)  with  lukewarm  water,  physiological  salt  solution 
or  very  dilute  antiseptic  solutions  (e.  g.,  potassium  permanganate,  0.5- 
1.0 :  2,000 ;  boric  acid,  0.5  :  1,000 ;  sublimate,  0.5-1.0  :  5,000 ;  besides  ace- 
tate of  aluminum,  menthol,  thymol,  salicylic  acid,  etc).  A  two  to  ten 
per  cent  solution  of  hydrogen  peroxide  with  the  addition  of  salt  solu- 
tion (for  mouth  wash  and  gargle)  has  become  very  popular.  It  has  a 
deodorizing  action  and  as  the  foam  develops  (free  oxygen)  it  cleans  the 
surface  mechanically. 

The  hygiene  of  the  mouth  cavity  is  very  important  in  preventing  the 
extension  of  the  inflammation  from  its  mucous  membrane  and  ad.jacent 
areas.  Less  importance  should  be  attached  to  tooth  pastes,  soaps,  and 
tinctures,  than  to  the  nnu'h  more  important  mechanical  cleansing  with 
toothbrushes  and  mouth  washes. 

Phlegmons  of  the  mucous  membrane  are  treated  according  to  general 
rules.     Complications  are  treated  according  to  their  indications. 

The  use  of  iodoform  gauze  is  recommended  for  resistant  ulcers,  where 
these  are  accessible.  AVhere  this  is  impossible,  they  may  be  painted  with 
iodoform  glycerin  emulsion  (von  IMikulicz).  Alcohol,  camphor  spirits, 
strong  caustics,  and  the  actual  cautery  may  be  used  if  necrosis  and  gan- 
grene develop.  In  all  severe  infections  the  general  nutrition  and 
conditions  should  be  improved,  for  in  this  w^ay  the  local  resistance  is 
increased. 

In  chronic  inflammation  one  per  cent  salt  solution,  mineral  water, 
such  as  Emser  and  Seltzer  water,  the  latter  w^arm  or  mixed  with  milk 
and  used  as  a  drink,  may  be  employed  for  gargles  and  inhalation.  One 
per  cent  tannin  and  alum  solution,  two  to  ten  per  cent  silver  nitrate  and 
iodin  glycerin  solution  may  be  applied  with  a  brush  or  cotton  swab. 
In  hypertrophies  cf  the  mucous  membrane  a  concentrated  solution  of 
silver  nitrate,  tannin,  etc.,  may  be  used.  Enlarged  palatal  and  pha- 
ryngeal tonsils  should  be  removed  by  operation,  as  they  may  give  rise  to 
recurrent  inflammation. 

Literature. — Askanazy.  Enteritis  phlegmonosa.  Zentralbl.  f.  allgeni.  Path.,  180"), 
p.  313.— /'VZer.  Die  Desinfektion  der  Mumlhohle.  I.-D.  Jena.  Wm.—IIasslaucr.  Die 
Bakterienfiora  der  gesunden  und  kranken  Nasenschleimhavit.  Zentralbl.  f.  Bakt.,  Bd. 
33,  Origin.,  1903,  p.  47. — Heymann.  Handb.  der  LarJ^lgologie  und  Hhinologie.  Wien, 
1899. — Kraus.  Die  Erkrankungen  der  Mundhfihle  nnd  der  Speiserohre.  In  Nothnagels 
Handb.  d.  spez.  Path.  n.  Ther.,  Bd.  16. — v.  Mikulicz  mid  KiimmcL  Die  Krankhciten 
des  Mundes.  Jena,  1898.— ^f^ller.  Die  Mikroorganismen  der  Mvuidhohle.  Leipzig, 
1892.— Stohr.  Ueber  die  Lyinjihknotchen  des  Darnies.  Arch.  f.  niikr.  Anat.,  Bd. 
33,  1889,  p,  255. 


226  WOUND   INFECTIONS   PRODUCED   JJY   BACTERIA 

(c)     PYOGENIC   INFECTIONS   OF   LYMPHATIC   VESSELS 
AND   NODES 

Bactericidal  Action  of  Lymphatic  Tissue. — Bacteria  and  their  toxins 
are  rapidly  absorbed  by  the  lymphatics  from  infected  woilnds  and  ulcers. 
The  endothelium  lining  the  lymphatic  vessels  may  be  injured  by  bac- 
teria and  their  toxins,  leading-  to  the  formation  of  a  thrombus  such  as 
occui's  in  throndiophlebitis,  which  will  be  described  later.  AVhile  in  the 
lymphatic  vessels  and  nodes  the  bacteria  which  have  been  carried  by  the 
lymphatics  are  exposed  to  the  bactericidal  substances  of  the  tissue  fluids, 
and  unless  present  in  large  numbers  or  very  virulent  they  are  destroyed. 
Under  certain  conditions  the  bacteria  may  pass  through  this  lymphatic 
barrier  and  produce  in  this  way  a  general  infection.  Absorption  is 
accompanied  by  marked  symptoms  only  when  the  bacteria  are  so  numer- 
ous or  so  virulent  that  they  are  not  destroyed  by  the  tissue  fluids,  or 
Avhen  their  endotoxins  which  are  freed  during  bacteriolysis  cause  in- 
flammation. If  the  bacteria  are  numerous  and  highly  virulent  the  tis- 
sues in  which  the  lymphatics  arise  and  those  composing  the  walls  of  the 
lymphatic  vessels  and  the  lymph  nodes  react  to  the  invasion,  and  an  in- 
flammation develops  which  retards  or  prevents  the  deposition  and  multi- 
plication of  the  bacteria.  Frequently  the  bacteria  extend  beyond  the 
lymphatics  and  invade  the  surrounding  tissues. 

Blood  infections  occur  after  lymphatic  involvement  only  when  the 
bactericidal  properties  of  the  lymph  nodes  have  been  so  reduced  that 
they  no  longer  offer  a  barrier  to  the  extension  of  the  bacteria  into  the 
larger  lymphatic  vessels. 

The  more  virulent  the  bacteria  the  earlier  the  lymphatic  vessels  and 
nodes  become  inflamed.  Lymphatic  involvement  may  be  exceedingly 
rapid  after  injuries  received  during  post-mortem  examinations  or  oper- 
ations, for  the  pus  found  in  fresh  cadavers  and  in  very  sick  patients 
frequently  contains  the  most  virulent  bacteria. 

Varieties. — Different  varieties  of  pyogenic  bacteria,  especially  staphy- 
lococci and  streptococci,  are  the  most  frequent  cause  of  acute,  more  rarely 
of  chronic  lymphangitis.  Lymphangitis  develops  from  recent  infected 
wounds,  from  suppurating  wounds,  ulcers,  and  granulating  surfaces, 
from  superficial  and  deep  inflannnatory  foci  and  inflamed  mucous  mem- 
branes. 

The  local  symptoms  of  acute  lymphangitis  are  most  striking  when 
the  superficial  lymphatics  of  the  skin  and  subcutaneous  tissues  are  in- 
volved. li.viiiphaMgitis  occui-s  most  frcfiuently  upon  the  exti-emities,  espe- 
cially iip(-ii  the  arms,  as  wounds  ol'  the  h.iiid,  wliicli  provide  the  infection 
atriinii,  are  wvy  common.  When  infection  oceui'S  at  the  pcunls  of  origin 
of  the  lymphatic  vessels  (e.  g.,  about  a  wound  or  excoriation  of  the  little 


THE   PYOGENIC    INFECTIONS   OF   DIFFERENT  TISSUES  227 

finger  or  a  furuncle  of  the  arm),  there  develops  a  marked  redness  of  the 
skin,  the  borders  of  which  an*  always  indistinct  and  extend  in  the  direc- 
tion of  the  lymph  stream.  Sometimes  the  inHannnation,  which  is  accom- 
panied by  an  itching  and  burning  and  a  sensation  of  fullness,  develops 
without  any  apparent  cause,  frequently  after  mechanical  irritation  of  the 
small  wound.  The  redness  may  be  diffuse,  mottled  or  netlike,  corre- 
sponding to  the  form  of  the  plexus  of  capillaries,  but  in  a  few  hours  a 
number  of  red  streaks  develop  from  the  reddened  area.  These  grad- 
ually fuse,  forming  one  or  more  streaks  which  correspond  to  the  main 
lymphatic  trunk  or  trunks  which  empty  into  the  painful  swollen  lymph 
nodes  of  the  axillary  fcssa,  lying  along  the  axillary  vessels.  The  streaks 
developing  in  a  lymphangitis  of  the  foot  extend  toward  the  popliteal 
fossa  or  upon  the  anterior  and  medial  surface  of  the  thigh,  where  they 
end  in  the  inguinal  lymphatic  nodes. 

In  from  one  to  two  days  the  redness  of  the  streaks  becomes  deeper 
and  the  lymphatic  vessels  impart  the  sensation  of  hard  cords,  which  are 
painful  when  palpated.  The  skin  of  the  extremity  involved  becomes 
moderately  swollen,  i)ainful,  and  tense. 

Inflannnation  of  the  deep  Ijnnphatic  vessels  is  indicated  by  a  dull, 
distressing,  rapidly  increasing  pain,  and  by  swelling  of  the  lymph  nodes 
into  which  they  empty.  Frequently  the  deep  lymphatics  are  involved 
alone  or  earlier  than  the  superficial. 

The  clinical  course  of  lymphangitis  is  sometimes  mild,  at  other  times 
severe,  depending  upon  the  bacteria  concerned,  the  character  of  the 
inflammation,  and  the  complications. 

A  superficial  lymphangitis  may  subside  in  from  one  to  two  days, 
nothing  remaining  but  a  slight  hypera^mia  and  a  sero-cellular  infiltration 
of  the  adventitia  and  adjacent  tissues,  which  rapidly  disappear.  The 
epithelium  covering  the  area  involved  exfoliates.  In  this  simple  form  of 
lymphangitis  new  streaks,  indicating  the  involvement  of  other  lymphatic 
vessels,  may  develop  for  several  days,  while  the  ones  which  have  devel- 
oped earlier  become  pale  and  disappear. 

In  other  cases  the  old  streaks  become  transformed  on  the  second  or 
third  day  into  hard  cords  the  size  of  the  little  finger.  In  these  cases 
the  walls  of  the  lymphatic  vessels  become  hyperaemic,  and  an  exudate  is 
poured  out  into  the  tissues  composing  and  surrounding  them.  The  endo- 
thelial cells  lining  the  vessels  become  swollen  and  are  cast  ofl:*,  and 
thrombi  of  different  lengths  containing  lymphocytes  and  endothelial  cells 
are  formed  by  the  coagulation  of  the  lymph.  Thrombus  formation  usu- 
ally begins  about  the  valves  of  the  lymphatic  vessels,  and  when  the  larger 
vessels  are  closed  (thrombo-lymphangitis)  a  stasis  of  lymph  develops. 

Involution  is  slow,  requiring  from  one  to  two  w^eeks,  and  while  it  is 
occurring  the  streaks  become  brown,  then  yellow,  the  oedematous  swelling 


228  WOUND   INFECTIONS  PRODUCED   BY   BACTERIA 

and  the  hard  cords  disappear,  for  as  the  hypenemia  subsides  the  thrombi 
soften  and  become  absorbed,  the  vessels  become  patent,  the  endothelium 
forms  again,  and  the  exudate  is  absorbed. 

The  suppurative  lymphangitis  is  the  most  severe  form.  The  inflam- 
mation then  spreads  from  the  hard  cords,  invades  surrounding  tissues, 
and  produces  subcutaneous  abscesses.  The  thrombi  undergo  septic  soft- 
ening, and  the  vessel  walls  become  necrotic.  Abscesses  develop  about  the 
lymphatic  vessels,  from  which  subcutaneous  phlegmons  may  originate  in 
the  first  or  second  week.  One  abscess  develops  from  another  after  long 
intervals,  and  in  this  way  the  inflammation  may  extend  over  long  periods. 

The  same  changes  occur  in  the  deep  Ijnnphatic  vessels  when  inflamed, 
but  only  the  supi)urative  form  gives  rise  to  distinct  symptoms  when  the 
inflaiumatory  exudate  having  become  purulent  reaches  the  skin. 

Complications. — Phlegmons  and  suppurative  lymphadenitis  are  the 
most  frequent  complications  of  lymphangitis.  Inflannnation  of  the  sub- 
cutaneous and  deep  veins  accompanied  by  thrombosis  may  develop  by 
direct  extension  of  the  inflannnation,  especially  when  suppurative,  from 
the  lymphatics  to  the  veins  innnediately  adjacent.  Metastatic  inflam- 
mation, especially  of  the  lungs,  is  much  less  frequent  in  lymphangitis 
than  in  thrombophlebitis  and  suppurative  lymphadenitis;  still  it  is  pos- 
sible for  a  part  of  a  lymphatic  thrombus  to  pass  through  a  diseased  gland, 
which  no  longer  retains  small  emboli  and  bacteria,  and  to  reach  the  heart. 

Frequently  a  mild  or  severe  lymphangitis  is  the  beginning  of  a  gen- 
eral infection,  and  not  infrefjuently  the  development  of  red  strealvs  in 
the  skin,  so  characteristic  of  lymphangitis,  is  the  first  indication  of  a 
beginning  erysipelas. 

The  severity  of  the  clinical  course  usually  depends  upon  the  viru- 
lence of  the  bacteria  and  the  resistance  of  the  patient.  Severe  general 
infections  not  infrequently  develop  from  wounds  received  during  post- 
mortem examinations  and  operations.  Severe  forms  of  lymphangitis  de- 
velop also  in  alcoholics,  diabetics,  and  patients  whose  resistance  has  been 
reduced  by  some  other  infection. 

Many  cases  are  very  resistant  to  treatment.  The  inflammation  accom- 
panied by  thi'(;mbosis  subsides  slowly,  and  symptoms  redevelop  when 
some  niovcnicnt  is  made  or  injury  received. 

The  (liafjiiosis  of  acute  l.ymphangitis  is  rarely  difficult.  The  inflam- 
mation about  the  point  of  infection  might  be  mistaken  for  a  subsiding 
<i\si|)clas  or  erysipeloid,  the  redness  of  which  has  no  longer  sharp  bound- 
aries. Iiym])hangitis  of  the  superficial  vessels  might  be  mistaken  for 
j)lilebitis,  but  the  cords  developing  in  the  latter  are  nmch  thicker;  lymph- 
angitis of  the  deep  vessels  for  an  inflannnation  (h^veloping  from  bone. 
The  latter  mistake  is  most  apt  to  be  made  when  the  lesion  develops  upon 
the  inner  side  of  the  arm,  in  the  poplit(>al  fossa  and  Scarpa's  triangle. 


THE  PYOGENIC   INFECTIONS  OF   DIFFERENT  TISSUES  229 

The  treatment  demands  absolute  rest  of  the  entire  extremity,  which 
should  be  obtained  by  a  loosely  .ipplicd  splint,  and  elevation  maintained 
as  long  as  any  red  streaks  are  to  be  seen  or  any  cords  to  be  felt.  ]\Ius- 
cular  movements,  rubbing-  and  massage,  Avhich  drive  the  lymph  onward, 
carrying  with  it  bacteria  and  particles  of  thrombi,  favor  the  develop- 
ment of  general  infection  and  are  to  be  avoided. 

An  ointment  usually  controls  tbe  pain.  Abscesses  should  be  incised 
when  they  form.  Constrictors  should  not  be  ai)plie(l  in  incising  an  ab- 
scess if  there  is  a  thrombo-lymphangitis,  as  particles  of  the  throudjus 
may  be  separated  and  forced  into  the  circulation. 

Chronic  forms  of  lymphangitis  develop  upon  the  extremities  after 
repeated  acute  attacks,  or  Avhen  there  is  a  continual  a])sorption  of  infec- 
tious materials  from  an  eczema,  an  ulcerated  area  of  the  skin,  etc.  After 
a  time  the  vessels  become  closed  as  a  result  of  the  organization  of  a 
thrombus  or  cicatricial  contraction  of  the  vessels,  and  a  lymph  stasis 
develops.  Chronic  lymphangitis  and  frequently  repeated  attacks  of 
erysipelas  are  important  etiological  factors  in  acquired  elephantiasis  or 
pachydermia.  In  the  treatment  of  chronic  lymphangitis  an  attempt 
should  be  made  to  remove  the  cause  and  to  prevent  the  stasis  of  lymph. 
Elevation  of  the  extremity,  supporting  dressings,  and  massage  should  be 
used. 

The  lymph  glands  (lymph  filters)  catch  and  retain  dust,  granules  of 
coloring  matter,  the  decomposition  products  of  cells  (e.  g.,  pigment  of 
red  blood  corpuscles),  and  of  absorbed  exudates  and  bacteria.  Dust, 
pigment  granules,  etc.,  remain  in  the  hanph  nodes  and  incite  merely 
tissue  changes  resulting  in  hyperplasia  or  cicatricial  contraction.  Bac- 
teria, however,  if  viable  and  capable  of  multiplying,  incite  inflammatory 
changes,  for  both  bacterial  and  animal  toxins  (e.  g.,  snake  venom)  when 
absorbed  by  the  lymphatics  produce  acute  or  chronic  inflammations 
which  may  end  in  pus  formation  if  pyogenic  bacteria  are  present. 

An  inflammation  of  the  lymph  nodes  occurs  with  every  inflammation 
of  the  area  which  they  drain.  Sometimes  only  one  lymph  node  becomes 
inflamed,  at  other  times  the  entire  chain.  The  lymphatic  vessels  carrying 
the  bacteria  are  frequently  not  involved,  at  other  times  they  are  severely 
inflamed. 

The  bacteria  are  usually  carried  to  the  lymph  nodes  ])y  the  lymph, 
but  hfpmatogenous  infections  may  also  occur. 

Lymphadenitis  may  pursue  an  acute  or  chronic  course;  the  cervical, 
axillary,  and  inguinal  lymph  nodes  being  most  frequently  involved. 

The  simple  form,  lymphadenitis  simplex,  is  usually  secondary  to 
some  mild  inflammation  of  the  area  drained  by  the  nodes  or  to  a  suppura- 
tive inflammation,  which  has  subsided  rapidly  under  proper  treatment. 
In  these  cases  many  small  lymph  nodes  may  be  palpated,  besides  the 
16 


230  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

one  primarily  involved,  wliieh  never  beeonies  larger  than  a  walnut  and  is 
round,  hard,  and  somewhat  painful.  As  there  is  little  or  no  periadenitis 
the  nodes  can  be  displaced  on  the  underlying  tissues  and  moved  freely 
under  the  skin,  which  is  not  reddened.  AYhen  the  cause  is  removed  the 
swelling  subsides.  If,  however,  the  infection  continues,  the  lymph  nodes 
may  undergo  a  chronic  hyperplasia. 

Upon  section  the  surface  of  the  involved  node  has  a  homogeneous, 
grayish  red  color.  It  is  hypera'iiiic  and  infiltrated  with  a  serous  or  sero- 
fibrinous exudate,  which  renders  the  capsule  tens(\  Histologically  there 
is  an  increase  in  the  number  of  lymphocytes  and  leucocytes  which  have 
migrated  through  the  walls  of  the  l)lo(id  vessels.  The  endothelial  cells 
lining  the  lymph  sinuses  have  been  cast  off.  As  resolution  occurs  the 
cells  and  the  exudate  are  absorbed,  the  hyperemia  subsides,  and  the  en- 
dothelial cells  regenerate. 

Suppurative  lymphadenitis  (lymphadenitis  purulenta)  is  accom- 
panied by  a  periadenitis.     There  are  tw^o  forms  clinically. 

The  first,  which  accom]ianies  severe  wound  infections  and  is  accom- 
panied by  pronounced  general  symptoms,  may  be  called  the  sero-suppura- 
tive  form.  It  is  usually  caused  by  streptococci,  and  has  a  tendency  to 
form  progressive,  subcutaneous,  and  intermuscular  phlegmons  of  the 
muscles  and  fascia  of  the  neck,  thorax,  and  abdominal  wall.  The  swollen 
lymph  nodes,  which  are  painful  to  touch  and  upon  motion,  can  no  longer 
be  distinctly  palpated  after  a  few  days,  as  the  inflammatory  oedema  of 
the  surrounding  tissues  renders  palpation  of  the  separate  nodes  impos- 
sible. The  skin,  which  is  somewhat  reddened,  is  adherent  to  a  fairly 
hard,  non-fluctuating  mass,  the  size  of  a  fist. 

AVhen  exposed  during  an  operation  the  individual  nodes  are  seen 
in  the  fcdenuitous  surrounding  tissues,  agglutinated  by  a  fibrinous 
periadenitis.  Upon  section  small  and  large  abscesses,  gray  necrotic  areas 
and  minute  ha-mon-hages  nuiy  be  recognized  in  the  dark  red  parenchyma. 
Small  absc-esses  may  be  found  in  the  fat  surrounding  the  lymph  nodes. 
Microscopically  the  lymi)li  sinuses  are  seen  to  be  filled  with  and  dilated 
by  fibrinous  masses,  which  contain  leucocytes,  red  blood  corpuscles,  and 
innumerable  bacteria.  The  latter  are  scattered  throughout  the  node.  If 
an  acute  progressive  phlegmon  has  already  developed,  the  nodes  will  be 
iiccrol  ic. 

The  second,  which  forms  abscesses,  may  develop  from  the  sero- 
suppurative  form.  As  a  rule,  it  pursues  a  mild  course  (subacute)  from 
the  beginning,  and  shows  first  the  characteristics  of  a  simple  inflamma- 
tion, and  produces  after  the  suppuration  extends  through  its  capsule 
(periadenitis  purulenta)  to  the  surrounding  tissues,  not  the  progressive, 
but  the  circumscribed  phlegmon.  Clinically  in  the  beginning  the  nodes 
are  hard  and  movable.     Gradually  they  become  fixed  and  adherent  to 


THE   PYOGENIC    INFECTIONS   OF    DIFFERENT   TISSUES  2ol 

the  reddened  skin,  soften  in  the  ceiitei-,  tiuetuatc,  and  seem  to  l)e  aliout 
ready  to  break  through  the  skin.  The  single  nodes  which  are  aggluti- 
nated suppurate.  Tlie  i)us  then  breaks  through  the  capsules  of  the 
separate  glands  and  forms  a  large  lymphadenitic  abscess,  which  may  dis- 
charge spontaneously.  Fever  and  general  symptoms  are  present,  as  a 
rule,  in  the  beginning  or  during  the  development  of  periadenitic  phleg- 
mons. The  inguinal  lymphadenitis  (or  inguinal  bubo)  following  the 
soft  chancre  belongs,  as  a  rule,  to  this  form  of  infection.  In  the  pus  of 
the  bubo  as  well  as  in  the  secretion  of  the  chancre  is  often  found  a  chain- 
like bacillus  (Ducrey,  Krefting,  Unna). 

The  bacteria  most  frequently  found  in  lymphadenitis  are  the  same 
as  those  in  lymphangitis.  Gonococci  have  been  found  in  the  so-called 
gonorrheal  bubo.  IMixed  infections  frequentl}^  occur.  If  infections  with 
putrefactive  bacteria  occur  the  clinical  picture  resembles  the  sero-sup- 
purative  form,  with  the  addition  of  the  gangrenous  destruction  of  the 
glands  and  their  surrounding  tissue. 

It  is  not  always  possible  to  demonstrate  bacteria  in  the  inflamed 
nodes.  It  is  easy  where  there  is  an  acute  inflannnation  which  has  ex- 
tended rapidly  to  the  surrounding  tissues.  If  an  abscess  of  a  lymphatic 
gland  has  persisted  for  some  time,  the  bacteria  are  frequently  attenuated 
or  dead.  In  a  simple  inflammation  of  a  lymph  node  the  bacteria  are 
quickly  killed. 

The  PHLEGMON  has  already  been  mentioned  as  one  of  the  complica- 
tions of  an  acute  lymphadenitis.  Where  the  glands  lie  directly  over  large 
veins  (jugular,  femoral,  saphenous,  axillary),  a  thrombophlebitis  may 
develop.  Pulmonary  infarcts,  followed  by  abscess,  may  develop  second- 
ary to  the  latter.  The  same  may  happen  if  the  glands  are  mechanically 
irritated  (rapid  movements,  trauma,  massage),  for  their  small  capsular 
veins  contain  thrombi  and  their  lyiiq)!!  sinuses  coagulated  masses  of 
flbrin  permeated  with  bacteria. 

Emboli  may  be  set  free  from  these  vessels,  even  after  the  symptoms 
of  the  inflammation  have  subsided.  Generai,  infection  is  another  com- 
plication, for  in  the  severe  wound  infections  which  are  accompanied  by 
lymphangitis,  erysipelas,  and  phlegmons  the  lymph  nodes  are  no  longer 
able  to  arrest  the  virulent,  incessantly  developing  bacteria. 

The  diagnosis  of  acutely  inflamed  lymph  nodes  is  not  difficult.  The 
position  and  mode  of  extension  of  a  fully  developed  phlegmon  or  abscess 
suggest  that  it  has  developed  from  lymph  glands. 

It  is  understood  that  in  the  treatment  attention  must  be  paid  to  the 
primary  focus.  The  diseased  glands  demand  rest  above  everything  else. 
Frequently  the  splint  applied  for  the  lymphangitis,  phlegmon,  etc.,  and 
simultaneously  elevation  of  the  extremity  cause  the  simple  inflammation 
of  the  gland  to  subside.     Any  movement,  likewise  auy  mechanical  irri- 


232  WOUND    INFECTIONS    rRODUCEL)    BY    BACTERIA 

tation  (b}^  rubbing-  in  of  ointments,  massage,  pressure  by  means  of  sand 
bags,  lead  plates,  which  are  intended  "  to  distribute  "  the  inflammation), 
is  dangerous  and  should  be  given  up,  for  it  forces  the  bacteria  and  coag- 
ulated serum  with  the  lymph  or  exudate  into  the  surrounding  tissues, 
if  not  into  the  blood. 

Agents  which  j)roduce  a  mild  hypera^mia,  such  as  mercury  oint- 
ment, tincture  of  iodin,  blur  the  local  changes  so  that  it  is  no  longer 
possible  to  recognize  the  inflammation  of  the  skin,  and  they  are  not 
superior  to  absolute  rest  obtained  by  an  immobilizing  dressing.  The 
moist  compress  is  of  value  in  simple  lymphadenitis,  for  example,  in 
the  neck,  as  it  lessens  the  pain.  In  suppurative  lymphadenitis  the 
compress,  as  well  as  poultices,  does  harm  {vide  Fundamental  Rules, 
p.  198). 

The  suppurative  forms  depending  upon  the  indications  are  to  be  ex- 
cised, incised,  or  aspirated.  In  the  severe  sero-suppurative  forms  all  the 
inflamed  nodes  should  be  removed  after  being  freely  exposed.  Simple 
incision  is  never  enough,  for  a  new  phlegmon  will  develop  from  the 
remaining  infected  nodes.  The  lymphatic  circulation  is  reestablished 
even  after  the  removal  of  all  the  nodes  by  a  proliferation  of  the  vessels 
in  the  surrounding  fatty  tissue  (Bayer). 

A  wide  incision  is  sufficient  in  the  form  which  results  in  abscess  for- 
mation, for  the  remaining  glands  are  extruded  and  the  inflammation  does 
not  extend.  Incision  is  necessary  when  there  is  fever  or  a  circumscribed 
phlegmon  develops.  If  the  abscess  is  limited  to  a  group  of  nodes,  punc- 
ture and  removal  of  the  pus  is  all  that  is  required.  Liquefaction  of  the 
nodes  which  have  not  softened  frequently  follows  the  injection  of  a  small 
amount  of  a  1  per  cent  solution  of  benzoate  of  mercury,  0.1  per  cent 
sublimate  solution,  or  of  physiological  salt  solution  (Welander,  Thorn, 
Walsch).  The  injection  treatment  is  especially  valuable  in  the  venereal 
bubo,  as  the  patient  is  not  compelled  to  remain  in  bed.  It  should  be 
employed,  however,  only  in  softened  glands,  for  the  injected  fluid  raises 
the  pressure  in  the  gland  and  carries  with  it  the  same  dangers  as  any 
other  mechanical  irritation. 

Blood  vessels  have  been  injured  in  making  incisions  and  punctures, 
because  of  carelessness  or  of  ignorance  of  the  anatomy  of  the  part. 

Rest  in  bed  is  necessary  as  long  as  there  is  fever. 

The  chronic  inflammation  of  lymph  nodes  (lymphadenitis  chronica 
simplex),  like  ehi-onic  lymphangitis,  is  produced  by  frequently  recur- 
ring, mild  inflammations  of  the  periphery,  or  by  the  continual  absorption 
of  iiiflamnintory  substances  from  a  chronically  iiifiamed  nnicous  mem- 
bratx'.  ail  (■czciiialoiis  oi-  iilcci-ilcd  skin  area. 

'i'iic  involved  nodes  are  eitliei-  enlarged  and  soft  and  present  micro- 
scopically the  picture  of  pure  hypertrophy,  or  they  are  small  and  hard, 


THE   PYOGENIC    INFECTIONS   OF   DIFFERENT  TISSUES  233 

because  ol*  the  liy[)ertr()pliy  and  coiit raclioii  oi'  tlieir  coiiiieetive  tissue 
trabecuhii  and  capsule  (Hl)i-<)us  liypei-i)lasia). 

Hypertrophied  cervical  ylands  accompany  eczema,  rhagades  of  the 
nose  and  lip,  and  catai'rh  of  the  mucous  membranes.  They  may  become 
tuberculous.  If  the  nodes  are  adjacent  to  a  carcinoma  and  are  indurated 
they  may  be  regarded  as  carcinomatous. 

The  treatment  of  chronic  lymphadenitis  usually  depends  upon  the 
cause. 

Literature. — F.  Fischer.  Krankheiten  der  Lymphgefiisse,  Lymphdriisen  und 
Blutgefiisse.  Deutsche  Chir.,  1901. — Thorn.  Behandlung  dor  Lcistenbubonen  niit 
Injektion  von  Hydrargyrum  benzoicum  oxydatuiu.  Deutsche  med.  Wochenschr., 
1897,  therap.  Beilage,  p.  49. 

(d)    THE   PYOGENIC   INFECTIONS   OF   BLOOD  VESSELS 

A  suppurative  inflammation  of  the  walls  of  arteries  and  veins  devel- 
ops when  an  inflammation  extends  to  the  vessels  from  an  adjacent  focus 
or  when  the  infection  is  carried  by  the  blood.  It  occurs,  therefore,  in 
areas  adjoining  and  in  foci  of  inflammation,  in  general  aiul  embolic  in- 
fections. 

Arteritis  purulenta  begins  as  a  peri-  or  as  an  endoarteritis,  de- 
pending upon  whether  the  bacteria  enter  the  vessel  from  Avithin  or 
without.  It  is  rarer  than  the  corresponding  inflammation  of  the  veins, 
as  the  arterial  walls  are  thicker  and  heavier.  The  pus  of  an  acute  or 
chronic  abscess  bathes  for  a  long  time  the  wall  of  a  lai'ge  artery  which 
is  separated  from  its  surrounding  tissue,  and  a  periarteritis  develops. 
This  occurs  often  in  the  large,  chronic  abscesses  of  the  neck  and  inguinal 
region,  which  have  thrived  upon  treatment  with  poultices.  Trauma  is 
also  a  factor,  for  the  suppurati(m  is  most  marked  where  the  arterial  wall 
has  been  crushed  during  ligation  (with  infected  ligatures),  as  in  an 
injury,  or  where  it  has  been  pressed  upon  by  a  drainage  tiil)e,  improperly 
placed. 

Endarteritis  develops  if  an  arterial  thrombus  laden  with  cocci 
suppurates,  or  if  an  infected  embolus  lodges  in  the  artery.  Bacteria 
may  pass  with  the  blood  stream  through  the  vasa  vasorum  and  lodge  in 
the  media  and  adventitia.  Thrombosis  with  necrosis  and  gangrene  then 
follow  the  inflannnatory  changes  in  the  vessel  wall  (as  in  iulhuMiza, 
typhoid  fever). 

Mild  inflammations  produce  merely  a  cellular  infiltration  and  thick- 
ening of  one  or  all  of  the  tunics  of  the  vessel  wall.  Inflannnatory  changes 
in  the  intima  (endarteritis  productiva)  may  result  in  obliteration  of  the 
lumen  of  the  vessel ;  severe  inflannnation  ending  in  suppuration  destroys 
the  vessel  wall. 


234  WOUND   INFECTIONS  PRODUCED  BY   BACTERIA 

If  necrcsis  of  the  suppuratiug  iiifiltratod  tissue  occurs,  the  vessel  wall 
becomes  eroded  and  ulcerated.  In  the  small  arteries  an  obturating  throm- 
bus, which  is  destroyed  if  necrosis  occurs,  frequently  prevents  haemor- 
rhage. Severe  hipmorrhage  follows  the  rupture  of  the  large  branches 
and  main  trunks.  This  haemorrhage  (secondary)  is  to  be  feared,  espe- 
cially in  large  necrotic  and  gangrenous  foci.  It  was  the  source  of  con- 
stant anxiety  to  the  military  surgeons  of  preantiseptic  times  in  their 
amputations  and  disarticulations.  If  the  vessel  ruptures  into  an  abscess 
cavity,  a  false  aneurysm  or  a  pulsating  hannatoma  develops.  The  devel- 
opment of  a  true  aneurysm  frequently  precedes  rupture  of  the  diseased 
vessel  wall. 

If  the  remaining  tunic  at  the  point  of  ulceration  (the  intima,  if  the 
supi:)uration  extends  from  without,  the  adventitia  if  from  within)  is 
forced  outward  or  its  entire  circumference  is  widened  before  being  rup- 
tured by  the  blood  pressure,  a  spontaneous  aneurysm  is  formed.  If 
an  infected  embolus  is  the  cause  of  this  dilatation,  the  aneurysm  is 
called  embolo-mycotic.  In  order  to  prevent  the  dangerous  arteritis  of 
the  large  vessels  in  inflannnatory  foci,  the  surgeon  should  be  careful 
in  incising  deep  phlegmons  and  abscesses  not  to  separate  the  connective 
tissue  sheath  of  the  large  vessels.  Where  a  ligated  artery  is  exposed 
in  a  suppurating  wound  (e.  g.,  a  suppurating,  therefore  open  ampu- 
tation-wound) it  should  be  supported  for  at  least  a  week  by  a  tampon, 
so  that  the  full  force  of  the  pulse  beat  is  not  expended  upon  the  arte- 
rial wall. 

The  development  of  an  embolic  aneurysm  often  indicates  threatened 
rupture  of  the  diseased  arterial  wall.  For  exanq)le,  if  a  pulsating  swell- 
ing, associated  with  severe  local  pain,  develops  within  a  few  days  in  a 
patient  suffering  with  endocarditis  or  general  infection,  and  a  few  days 
before  this  sudden  circulatory  disturbances  occurred  in  the  extremity 
which  made  pi'obable  the  diagnosis  of  embolism ;  double  ligation  of  the 
vessel  should  be  made,  as  in  hu'inorrhage,  above  the  diseased  area  in 
healthy  non-inHaiiuHl  tissue.  Suppurative  phlebitis  (phlebitis  puru- 
lenta)  freciueiitly  begins  as  a  periphlebitis  associated  with  an  inflamma- 
tion of  the  lymphatic  vessels  surrounding  or  accompanying  the  large 
veins,  or  follows  the  extension  of  an  acute  suppui'ative  inflammation 
from  the  cellular  tissue  surrounding  the  vein.  If  the  inflannnation  de- 
velops from  the  lumen,  thrombosis  and  infection  through  the  blood 
stream  precede  it.  I71  an  inflamed  area  even  the  snuillest  veins  are  in- 
volved, for  the  inflammatory  slowing  of  the  blood  sti-eam  and  stasis  favor 
the  formation  of  llu-ombi  and  the  growth  of  bacteria.  ]\lild  inflamma- 
tions whicli  do  not  end  in  suppuration  produce,  when  subcutaneous  veins 
are  involved,  ))ainf'ul  hard  cords  of  flnger  thickness  which  may  be  pal- 
pated under  a  reddened  skin.     The  clinical  picture  resembles  somewhat 


THE  PYOGENIC   INFECTIONS  OF   DIFFERENT  TISSUES  235 

that  of  thronibolvDiphangitis.  These  intlainmations  may  subside  com- 
pletely; the  thrombus  is  then  organized  or  absorbed,  the  lumen  becomes 
closed  or  patent.  This  may  occur  even  in  large  vessels.  Frequently  recur- 
ring inflammation  of  veins  (occurring  in  the  leg  with  varicose  ulcers)  pro- 
duces a  chronic  thickening  of  all  the  coats  with  a  narrowing  or  oblitera- 
tion of  the  lumen  (phlebitis  chronica  hyperplastica).  If  the  organizing 
thrombus  becomes  partially  calcified,  vein  stones  or  phleboliths  are  formed. 
Severe  inflammations  lead  to  a  purulent  inflltration  of  the  vein  Avail  and 
surrounding  tissues,  and  during  the  operation  the  yelloAvish,  discolored, 
rigid,  and  thickened  vein  is  found  in  suppurating  or  oedematous  tissue. 
Venous  thrombosis  occurs  constantly  with  suppurative  phlebitis.  The  co- 
agulation is  produced  by  the  bacterial  toxins  (Talke)  which  penetrate  the 
intima,  and  by  the  inflammatory  exudate  which  is  poured  out  from  the 
vasa  vasorum  (thrombophlebitis  purulenta).  The  converse  is  true,  that 
phlebitis  follows  suppuration  of  a  thrombus.  After  suppuration  of  the 
thrombus  and  destruction  of  the  vein  wall,  the  pus  escapes  from  the 
lumen  of  the  vessel  into  the  surrounding  tissues  and  produces  an  abscess, 
a  progressive  suppurative  inflammation,  or  becomes  mixed  with  the  exu- 
date which  is  already  present.  Haemorrhage  rarely  occurs,  for  the 
thrombus  while  softening  has  extended  and  has  closed  the  vein  proxi- 
mally  and  distally.  The  diagnosis  of  thrombophlebitis  of  subcutaneous 
veins  is  not  difficult.  It  may  be  mistaken  for  a  thromboljanphangitis. 
The  diagnosis  of  inflammation  of  deep  veins  may  be  made  by  the  pres- 
ence of  oedema,  by  the  palpation  of  hard,  painful  cords  corresponding 
to  the  position  of  veins,  severe  pain,  the  presence  of  a  local  cause  (such 
as  varicose  ulcer),  and  general  symptoms.  The  following  are  the  dangers 
which  accompany  thrombophlebitis : 

All  extension  of  the  inflammation  along  the  vein.  A  suppurative 
meningitis  may  follow  a  furuncle  of  the  lip,  as  the  inflammation  extends 
along  the  facial  to  the  ophthalmic  vein  and  to  the  cavernous  sinus.  A 
phlegmon  of  the  scalp  extends  to  the  veins  of  the  diploe  and  dura,  whil' 
inflammation  of  the  umbilical  vein  may  be  the  cause  of  a  fatal  peritonitis 
in  the  newborn.  A  thrombophlebitis  of  the  veins  of  the  puerpei-al  uterus 
extends  along  the  spermatic  and  hypogastric  veins  to  the  common  iliac 
and  femoral  veins  and  the  inferior  vena  cava.  The  inflammaticm  extends 
with  the  growth  of  the  thrombus  against  the  blood  stream.  The  veins  of 
the  mesentery  become  inflamed  in  perityphlitis  and  severe  enteritis,  and 
the  inflammation  may  extend  to  the  portal  vein. 

The  second  danger  is  the  separation  of  emhoU  ivhieh  eontaiii  bac- 
teria from  snppurating  thrombi.  Thrombophlel)itis  may  thus  become 
the  cause  of  a  metastatic  inf(>ction.  Any  trauma  or  movement  may 
separate  or  set  loose  an  embolus  in  the  small  and  large  veins.  As 
there  are  venous  thrombi  which  contain  bact(M-ia  in  every  inflamed  area, 


236  WOUND   INFECTIONS   TRODUCED   BY   BACTERIA 

this  danger  must  be  kept  in  mind  in  the  treatment  of  all  pyogenic 
infections. 

The  treatment  of  acute  thrombophlebitis  demands  in  the  first  place 
absolute  rest  of  the  extremity  involved.  This  is  obtained  by  immobilizing 
dressings  and  rest  in  bed,  which  should  be  continued  as  long  as  there  are 
any  signs  of  inflammation.  Abscesses  should  be  incised.  If  chills,  a 
high  remittent  fever,  general  symptoms,  and  those  of  lung  embolism 
lead  to  the  suspicion  that  a  demonstrable  thrombus  is  suppurating 
and  breaking  down,  ligation  and  resection  of  the  vein  above  the 
thrombus  (if  possible  resection  of  the  diseased  portion,  or  at  least  re- 
moval of  the  suppurating  thrombus)  prevents  in  many  cases  general 
infection.  The  inflamed  subcutaneous  veins  of  the  arm  and  leg  (Lee, 
W.  MuUer)  and  the  femoral  vein  (Kraussold)  have  been  ligated  with 
success.  The  internal  jugular  vein  is  ligated  in  thrombosis  of  the  trans- 
verse sinus  following  suppurative  otitis  media  (Zaufal),  and  the  facial 
vein,  when  inflamed,  secondary  to  carbuncle  of  the  face.  Trendelenburg 
records  a  case  of  general  chronic  puerperal  infection  which  recovered 
after  double  ligation  of  the  inflamed  and  thrombosed  right  hypogastric 
and  spermatic  veins. 

Literature. — v.  Biingner.  Spontanruptur  der  Art.  femoralis.  Arch.  f.  klin. 
Chir.,  Bd.  40,  1890,  p.  312. — Fr.  Fischer.  Krankheiten  der  Lymphgefasse,  Lymph- 
driisen  und  Blutgefasse.  Deutsche  Chir.,  1901. — Frommer.  Zur  Kasuistik  der  Nach- 
blutungen.  Arch.  f.  klin.  Chir.,  Bd.  67,  1902,  p.  439.— W.  Miiller.  Zur  operativen 
Behandlung  infektioser  und  benigner  Venenthrombosen.  Arch.  f.  klin.  Chir.,  Bd.  66, 
1902,  p.  642. — Nasse.  Mykot.  Aneurysma  der  Art.  femoralis.  Deutsche  med.  Wochen- 
schr.,  1898,  Vereinsbeilage,  p.  259. — Talke.  Experim.  Beitrag  zur  Kenntnis  der  in- 
fektiosen  Thrombose.  Beitr.  z.  klin.  Chir.,  Bd.  36,  1902,  p.  339. — Trendelenburg.  Ueber 
die  chir.  Behandlung  der  puerperalen  Pyamie.     Miinch.  med.  Wochenschr.,  1902,  p.  513. 

(e)     PYOGENIC   INFECTIONS   OF   BONE 

Etiology. — Bone  may  be  infected  in  three  ways:  1.  In  compound 
fracture  or  in  operations  such  as  amputations,  joint  resections,  and  oste- 
otomies, in  which  the  medullary  cavity  or  the  surface  of  the  bone  stripped 
of  its  periosteum  is  directly  exposed  to  infection.  2.  A  suppurative  in- 
flammation of  the  surrounding  soft  tissue  may  extend  to  the  bone,  and 
it  may  become  involved  sec(mdarily.  3.  The  infection  may  be  carried 
through  the  blood  by  bacterial  or  infected  emboli,  which  lodge  in  parts 
of  the  bone  where  anatomical  conditions  are  favorable  or  where  a  locus 
minoris  resisffvtia>  has  been  provided  by  some  previous  injury  or  circu- 
latory disturbance. 

The  chissification  of  suppurative  inflammation  of  bone  is  based  en- 
tirely, or  almost  ctiiii-cly,  upon  the  tissues  involved.^  Inflammation  of  the 
periosteum  is  called  periostitis;  of  the  bone  marrow,  osteomyelitis;  of  the 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT  TISSUES 


237 


cortex,  osteitis.  Usually  when  all  the  different  tissues  of  the  bone  are 
involved  some  collective  term  is  required :  osteitis  as  well  as  osteo- 
myelitis being  used   in  this  sense. 

^ny  pyogenic  organism  may  be  the  cause 
of  osteomyelitis.  In  the  ectogenous  infec- 
tions, and  those  extending  from  inflammatory 
foci  in  the  surrounding  soft  tissues,  the  staph- 
ylococcus aureus  and  albus  and  the  strep- 
tococcus, often  associated  with  other  bacteria 
(e.  g.,  putrefactive),  are  most  frequently 
found.  In  ha^matogenous  osteomyelitis  the 
staphylococcus  pyogenes  aureus  is  found 
with  by  far  the  greatest  frequency;  then 
follow  next  in  order  of  frequency  mixed  in- 
fections with  the  aureus  and  albus  and  the 
aureus  and  the  streptococcus.  The  white 
staphylococcus  and  the  streptococcus  are 
more  rarely  found  alone.  The  pneumococ- 
cus,  typhoid  bacillus,  the  gonococcus  and 
bacillus  of  pneumonia  are  also  found  in  os- 
teomyelitic  foci,  but  cases  of  osteomyelitis 
caused  by  these  bacteria  are  relatively  rare 
when  compared  to  those  caused  by  the  bac- 
teria above  mentioned. 

Pathology. — The  pathological  changes 
eventually  are  the  same  whether  the  in- 
flammation attacks  the  bone  from  within  or 
without,  the  order  in  which  the  tissues  are 
involved  being  merely  reversed. 

If  the  inflammation  develops  from  with- 
out, as  occurs  most  frequently  after  an  in- 
jury, or  secondary  to  a  phlegmon,  a  perios- 
titis develops  first,  the  periosteum  becoming 
swollen  and  reddened  and  raised  from  the 
bone  by  a  layer  of  pus.  The  inflammation 
next  extends  along  the  vessels  of  the  Haver- 
sian canals,  and  the  cortex  of  the  bone  be- 
comes involved.  In  the  short  and  flat  bones 
an  inflammation  beginning  in  the  periosteum 
frequently  extends  to  the  medulla.  In  a 
suppurative  arthritis  accompanied  by  a  de- 
struction of  the  articular  cartilage,  the  spongy 
bone  of  the  epiphysis  is  involved,  and  in  com- 


9 

FlC.  101. Sln'PIIRATIVE  OSTKO- 

MYEI.ITIS  OFTIIE  TlHIA  (SkMI- 

DiAGRAMMATic).  (t.  Attach- 
ment of  capsular  ligament ;  h, 
purulent  focus  in  mctaphysis 
which  has  ruptured  into  the 
epiphysis;  c,  periosteum 
raised  by  jjus;  d,  phlegmon 
of  the  medulla;  e,  separation 
of  the  epiphj-sis;  /,  extracap- 
sular rujiture  of  pus;  g,  cap- 
sular ligament;  h,  rupture 
into  joint. 


238 


WOUND   INFECTIONS   PRODUCED    BY   BACTERIA 


pound  fractures  in  which  the  medulla  is  exposed  infection,  if  it  occurs, 
travels  rapidly  along  the  medullary  cavity. 

In  HEMATOGENOUS  INFECTIONS  the  medulla  is  usually  primarily  in- 
volved, occasionally  the  cortex  and  periosteum.  When  the  infection 
begins  in  the  medulla,  it  may 
travel  in  a  number  of  different 
ways.  The  acute  progressive  in- 
fections of  the  medulla  (medul- 
lary   phlegmons)    are    frequently 


I'iG.    102. TuiilLAK    .Skqi'kstrum. 


P'iG.  103. — Total  Nkckosis  of  the  Humerus. 
Involucrum  with  sequestrum  and  cloaca;. 


limited  by  the  epiphyseal  cartilages,  but  not  infrequently  the  union 
between  the  metaphysis  ^  and  the  epiphyseal  cartilage  is  destroyed  and 
the  epiphysis  becomes  separated. 


'  Metaphysis — a  term  used  by  Kocher  to  designate  the  spongy  end  of  the  diaph- 
ysis  lying  next  to  the  epiphysis  (Fig.  101).  A  suppurating  focus  situated  in  the 
metaphysis  near  the  epiphyseal  cartilage  may  produce:  h  A  medullary  phlegmon. 
2.  Extending  along  the  epijjhyseal  cartilage,  a  .separation  of  t  lie  epi|)hysis.     3.  Passing 


THE   PYOGENIC   INFECTIONS   OF    DIFFERENT  TISSUES 


239 


As  the  inflaiiiiiialidii  extends  rai)i(lly  outward  alon*;  the  Haversian 
canals,  the  vessels  of  wliieh  become  eh)sed  by  thrombi  as  a  result  of  the 
inflammation,  a  medullary  phlegmon  is  usually  accompanied  by  a  sup- 
purative periostitis  of  the  same  extent.  The  periosteum  is  raised  from 
the  bone  by  a  thick  layer  of  pus,  which  finally  ruptures  through  it  at  a 
number  of  different  points,  Avhere  it  becomes  necrotic.  The  compact 
bone  bathed  in  pus  without  and  within,  deprived  of  nutrition  by  the 
separation  of  the  periosteum 
and  thrombosis  of  the  medul- 
lary vessels  and  those  in  the 
Haversian  canals,  becomes  ne- 
crotic (necrosis  totalis).  If 
only  the  inner  layers  of  the 
shaft  or  the  deeper  spongy 
bone  becomes  necrotic,  one 
speaks  of  a  central  necrosis 
in  contradistinction  to  the  ex- 
ternal or  superficial  necrosis, 
which  occurs  in  periosteal  or 
cortical  suppuration. 

The  bloodless  white  bone, 
killed  by  the  suppurative  in- 
flammation and  permeated  with 
bacteria,  excites  and  maintains 
in  the  living  bone  surround- 
ing it  a  reactive  inflammation 
which  may  be  rarefying  or  de- 
marcating as  well  as  osteoplas- 
tic. Granulation  tissue  devel- 
ops at  the  boundary  between 
the  living  and  dead  bone  from 
the  healthy  marrow,  the  spon- 
gy bone,  and  the  Haversian 
canals.  This  tissue  gradually 
develops  to  such  an  extent 
that  the  space  (demarcation 
pit)  between  the  dead  (sequestrum)  and  the  healthy  bone  is  completely 
filled.     The  sharp  and  jagged  form  of  an  old  sequestrum  penetrated  by 

through  the  epiphyseal  cartilage  where  pierced  by  canals  for  Ijlood  vessels  an  inflam- 
mation of  the  epiphysis.  4.  Extending  through  the  epiphysis  a  suppurative  arthritis. 
5.  Passing  along  the  epiphyseal  cartilage  and  rupturing  through  the  periosteum  an 
intra-  or  extra -articular  abscess,  depending  upon  the  insertion  of  the  capsular  liga- 
ment. 


Fk; 


104. ToT.\L   NkcKOSIS  ok  THK  Hl-.MKIU'; 

8ki;n-  IX  A  Roentgen  II.\y  Pictuke. 


240  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

canals  and  traversed  by  grooves  is  due  to  the  digestive  action  of  the 
granulation  tissue  and  not  to  the  pus  (von  Volkniann).  It  differs  from 
the  even  symmetrical  absorption  or  necrosis  of  fresh  macerating  bone. 
The  total  and  central  sequestra  of  the  diaphysis  are  cylindrical  or  tubu- 
lar in  shape,  while  cortical  sequestra  resemble  a  disk  or  chip.  AVeeks 
and  months  are  required  for  a  complete  separation  of  a  sequestrum, 
depending  upon  the  extent  of  the  necrosis.  Often  half  a  year  is  re- 
quired for  the  separation  of  a  large  sequestrum  of  the  diaphysis.  If 
superficial,  the  separated  sequestrum  may  be  discharged  with  the  pus 
when  it  ruptures  externally,  or  it  may  remain  and  be  digested  and 
absorbed  by  the  granulation  tissue.  Only  very  small  sequestra,  most 
frequently  those  derived  from  spongy  bone,  can  be  destroyed  in  this 
way. 

During  the  separation  and  erosion  of  the  sequestrum  reparative  proc- 
esses leading  to  the  formation  of  new  bone  are  going  on.  The  perios- 
teum takes  a  very  active,  the  medulla  and  surrounding  intermuscular 
tissue  a  less  active,  part  in  this  new  bone  formation.  These  reparative 
processes  are  most  active  in  long  hollow  bones;  least  so  in  flat  bones. 
Early,  often  within  a  week,  the  inner  layer  of  the  periosteum  (cambium, 
germinal  layer)  begins  to  develop  delicate  layers  of  spongy  bone  (peri- 
ostitis ossificans).  This  proliferation  continuing  gradually  produces  in 
the  course  of  months  a  bony  shell,  which  in  the  beginning  is  thin,  fragile, 
and  porous,  like  pumice  stone.  Later  it  becomes  thicker,  shapeless,  and 
sclerotic,  surrounding  the  dead  bone  or  sequestrum  like  a  capsule.  This 
newly  formed  bone,  which  is  separated  from  the  sequestrum  by  a  thin 
layer  of  granulation  tissue  deficient  at  sonu^  points,  and  pus,  is  called 
the  involucrum   (capsula  sequestralis). 

Canals  of  different  sizes  (cloaca^)  lined  with  granulation  tissue 
through  which  is  discharged  the  pus  forming  in  the  interior  are  found 
in  tlu'  involucrum.  The  involucrum  is  deficient  and  weakened  where  the 
periosteum  has  become  necrotic,  and  if  weight  is  brought  to  bear  upon 
the  bone  or  it  is  manipulated  roughly  the  involucrum  may  be  fractured. 
If  the  involucrum  is  fi-actured  union  may  not  occui',  a  pseudarthrosis 
developing.  AVhen  the  newly  formed  bone  hardens  the  involucrum  ceases 
to  increase  in  size  (von  Volkniann).  The  spongy  and  compact  bone  may 
become  so  thickened  and  condensed  as  a  result  of  tlie  reactive  inflamma- 
tion, that  the  suri-ounding  bone  becomes  as  liai'd  as  ivory  (osteomyelitis 
ossificans,  sclerotieans,  eburnatio).  This  ossifying  or  sclerotizing  process 
may  involve  an  area  5  cm.  in  width  surrounding  a  suppurating  focus  or 
a  sequestrum  in  spongy  bone. 

This  luu'd  bone  developing  about  a  total  se(|uesti'um  of  tlu^  shaft  may 
entirely  fill  up,  or,  as  happens  in  the  chronic  sclerotizing  forms  of  osteo- 
myelitis, entirely  ol)l  iterate  the  medullary  cavity. 


THE   PYOGENIC    INFECTIONS   OF    DIFFERENT   TISSUES  241 

Clinical  Course. — The  clinical  course  and  picture  of  suppurative  osteo- 
myelitis differ  widely,  the  dififerences  dependinf?  upon  the  virulence  of 
the  hacteria,  the  susceptibility  of  the  tissues  and  of  the  patient,  the  loca- 
tion and  predisposing  cause,  such  as  trauma,  exposure  to  cold,  etc.,  the 
complications  (suppurative  arthritis  and  metastatic  infections),  the  pre- 
dominance of  necrotic  or  osteoplastic  processes. 

The  haematogenous  is  the  most  important  form  of  suppurative  osteo- 
myelitis. The  way  in  which  this  form  of  osteomyelitis  develops  has  been 
made  clear  by  a  number  of  very  conclusive  pieces  of  experimental  work. 

If  a  small  amount  of  a  virulent  culture  of  staphylococcus  pyogenes 
aureus  is  injected  into  the  vein  of  a  young  rabbit  or  guinea  pig,  the 


Fig.  105. — Tibia  of  a  Young  Rabbit  with  a  Total  Sequestrum  of  the  Diaphysts, 
Developing  Three  Months  After  an  Intravenous  Injection  of  an  Attenuated 

Culture  of  Streptococci.      (|  natural  size.) 

animal  develops  a  fever  and  dies  within  a  few  days,  and  a  post-mortem 
examination  reveals  numerous  abscesses  in  the  viscera,  muscles,  bones, 
and  joints.  The  smaller  the  amount  of  the  culture  injected  the  more 
marked  the  development  of  abscesses  in  the  bones,  the  less  marked  their 
development  in  other  parts  of  the  body.  The  abscesses  developing  in 
the  bones  are  most  commonly  situated  in  the  broad  metaphysis  of  the 
femur,  the  upper  end  of  the  tibia,  and  in  the  upper  extremity  of  the 
humerus.  The  disease  procured  in  animals  experimentally  is,  like  severe 
osteomyelitis  occurring  in  man,  a  fatal  general  infection  accompanied  by 
the  formation  of  metastatic  foci  developing  especially  in  bones  (Rodet, 
Colzi,  Lannelongue  and  Achard,  Lexer). 

Similar  results  may  be  obtained  by  the  injection  of  the  staphylococcus 
pyogenes  albus,  and  the  streptococcus  pyogenes  (Lannelongue  and 
Achard,  Lexer)  and  the  bacterium  coli  commune  (Ackermann). 

If  old  attenuated  cultures  of  the  yellow  or  white  staphylococcus  are 
injected  the  animal  remains  sick  for  a  short  time,  but  recovers.  During 
the  course  of  the  sickness  several  hot  painful  swellings  develop  upon 
one  or  more  legs,  and  as  the  swelling  of  the  soft  tissues  subsides  the 
thickening  of  the  bones,  which  after  two  or  three  weeks  present  all  the 
pathological  changes  of  chronic  suppurative  osteomyelitis  (osteomyelitis 
purulenta  chronica),  as  it  occurs  in  man,  becomes  more  distinct. 

It  is  impossible  to  produce  in  animals  by  the  iiiti-avenous  injection  of 


242 


WOUND   INFECTIONS   PRODUCED    BY    BACTERIA 


Staphylococci  au  acute  progressive  medullary  phlegmon,  unless  an  inflani- 
matiou  has  been  produced  by  the  previous  injection  of  some  other  organ- 
ism, e.  g.,  a  pyogenic  bacillus  which  occurs  frequently  in  rabbits  (Lexer). 
Trauma  has  an  actual  influence  in  determining  the  location  of  and 
contributing  to  infections  in  experimental  animals.  Extensive  suppura- 
tion develops  at  the  seat  of  fractures  or 
where  the  bones  have  been  injured  after  the 
intravenous  injection  of  virulent  cultures 
made  at  the  same  time  or  some  days  later 
( Ullmann ) . 

Animal  experiments  have  shown  that  pyo- 
genic bacteria,  and  of  these  most  frequently 
the  staphylococci,  may  be  deposited  by  the 
blood  stream  in  young;  growing  bones  pro- 
ducing suppurating  foci  which  are  situated 
as  in  man  in  the  metaphysis  of  the  long,, 
hollow  bones,  and  in  parts  of  the  bones  the 
resistance  of  which  has  been  reduced  (locus 
MiNORis  resistenti/e)  by  some  trauma,  ex- 
posure to  cold,  etc. 

The  micro-organisms  may  be  absorbed 
from  any  inflammatory  focus,  no  matter  how 
small,  or  may  be  carried  in  emboli  (infected 
emboli),  or  in  groups  (bacterial  emboli), 
from  the  veins  of  the  primary  suppurating 
focus,  which  have  become  closed  by  thrombi. 
It  may  be  impossible  to  demonstrate  the  pri- 
mary focus,  but  a  suppurating  focus  in  bone 
is  proof  positive  that  a  primary  focus  exists 
or  has  existed  in  each  case  (Jordan). 

The  absorption  of  bacteria,  which  may 
occur  in  any  wound  infection  and  bacterial 
invasion,  leads  to  the  development  of  a  sup- 
purative osteomyelitis  only  when  special  con- 
ditions are  provided.  The  bacteria,  unless 
present  in  large  numbers  or  continually  in- 
vading the  ])]ood,  are  deposited  in  the  bone 
marrow,  spleen  and  liver  (Wyssoko witch), 
where  they  are  exposed  to  the  action  of  the 
bactericidal  substances,  which  in  the  bone 
niai'i'ow  are  formed  especially  by  tlie  1(M1co- 
cytes.  Here  Ihey  are  either  killed  or  so  injured  by  l)actericidal  sub- 
stances that  they  can  no  longer  multiply  and  invade  the  tissues    (A. 


^rff 


Fk;.  1 1)  I  I  I, Mil:  (11-  \  Cirii,!) 
FoTJH  Wkeks  Old,  the  Ves- 
sels OF  Which  Have  Been 
Injected,  as  Seen  in  a 
Roentgen  Ray  Picture 
(Periosteum  and  Capsu- 
lar Ligaments  Dissect- 
ed Away).  a,  Epiphyseal 
firtorios;  6,  motapliysfjil  ar- 
trxios;  c,  double  imlticnt 
arteries. 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT   TISSUES  243 

Wasserniann).  In  iiiaiiy  infections  the  Ixtnc  niairow  is  move  active 
than  any  other  tissue  in  producing  the  specific  iuiiiiune  Inxlies,  and 
therefore  the  deposition  of  bacteria  in  it  may  be  regarded  in  the  light 
of  a  protective  measure,  as  the  bone  marrow  destroys  the  bacteria  and 
produces  substances  which  are  at  the  disposal  of  the  organism  in  com- 
bating infections. 

E.  Fraenkel,  and  earlier  Weichselbaum,  demonstrated  in  the  bone 
marrow  of  patients  dying  of  pneumonia,  felons,  phlegnums,  and  erysipe- 
las, the  bacteria  which  had  produced  these  lesions  even  when  there  had 
apparently  been  no  blood  infection.  One  must  conclude,  therefore,  tliat 
bacteria  are  often  deposited  in  the  bone  marrow  even  when  the  local  in- 
fection and  the  general  reaction  is  not  severe. 

If  the  pyogenic  bacteria  are  present  in  the  bone  marrow,  one  of  two 
conditions  must  be  fulfilled  before  they  can  produce  suppuration.  The 
bacteria  must  either  be  virulent  enough  or  present  in  large  enough  num- 
bers to  resist  the  bactericidal  substances,  or  the  tissues  must  be  so  weak- 
ened by  trauma  or  circulatory  disturbances  that  they  can  no  longer 
produce  these  substances  in  large  enough  amounts  to  restrain  the  growth 
of  the  bacteria  (A.  Wasserniann). 

Osteomyelitis  may  also  be  produced  by  the  displacement  and  lodg- 
ment of  infected  or  bacterial  emboli  from  the  primary  focus,  which 
always  contains  veins  which  have  been  closed  by  thrombi  or  invaded  by 
bacteria.  Osteomyelitie  foci  which  are  intimately  related  to  the  arterial 
branches  and  are  situated  in  the  epiphyseal  zone  to  which  capillaries 
from  all  sides  converge,  and  the  foci  in  the  short  and  flat  bones  (e.  g., 
vertebra,  pelvis,  phalanges)  most  frequently  attacked  by  tuberculosis, 
must  be  regarded  as  of  embolic  origin  (Lexer).  The  vertebra^,  pelvis, 
and  phalanges,  etc.,  are  much  less  frequently  the  seat  of  suppurative 
than  tuberculous  lesions,  and  embolism  (by  infected  or  bacterial  emboli) 
is  apparently  much  less  frequent  in  suppurative  than  in  tubercalons 
osteomyelitis. 

Suppurative  foci  are  more  frequent  in  the  metaphysis  of  long  bones 
than  in  any  other  bones  of  the  skelet(m.  The  frequency  of  the  lesions 
in  the  metaphysis  cannot  be  satisfactorilv  explained  upon  the  suppi^si- 
tion  that  the  bacteria  are  attracted  by  the  bactericidal  substances,  for 
theoretically  the  diaphysis  is  as  rich  in  these  as  the  metaphysis ;  neither 
can  it  be  explained  satisfactorily  by  the  lodgment  of  emboli,  for  other 
bones  should  then  be  attacked  as  frequently.  The  mechanical  conditions 
provided  in  the  epiphyseal  zone  of  growing  bones,  in  Avhich  there  is  a 
physiological  hypera^mia  with  a  slowing  of  the  blood  stream,  and  by  the 
arrangement  of  the  smaller  vessels  and  the  capillary  loops  with  their 
branches  M-hieh  pass  down  into  the  primary  medullary  spaces  of  the  epi- 
physeal cartilage  (Langer),  favor  the  deposition  and  retention  of  bac- 


244  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

teria  and  explain  the  frequency  of  acute  suppurative  lesions  in  this  part 
of  the  bone. 

The  fact  that  staphylococci  are  retained  in  these  vessels  and  cause 
suppurative  osteomyelitis  more  frequently  than  any  other  variety  of 
bacteria,  must  be  ascribed  to  their  peculiarity  of  growth,  occurring  as 
they  do  in  groups  or  clumps.  If  such  a  group  gradually  forms  in  these 
vessels,  or  if  a  group  is  carried  from  a  primary  focus,  or  if  two  or  more 
clumps  fuse,  the  small  vessel  is  closed  and  the  foundation  for  a  suppu- 
rative osteomyelitis  is  laid. 

The  yellow  staphylococci  are  found  more  frequently  than  the  white  in 
these  lesions,  as  the  former  occur  more  frequently  in  the  primary  lesions 
in  the  skin,  mucous  membrane,  etc. 

H.EMATOGENOUS  SI^PPURATIVE  OSTEOMYELITIS  MAY  BE   CAUSED: 

1.  By  the  deposition  of  highly  virulent  bacteria  in  the  bone  marrow. 

2.  By  the  lodgment  of  infected  or  bacterial  emboli. 

3.  By  the  development  or  fusion  of  clumps  of  staphylococci  in  the 
finest  capillaries. 

4.  The  relation  of  trauma  to  osteomyelitis  must  also  be  considered. 
The  relation  between  trauma  (in  the  broadest  sense,  fractures,  contu- 
sion, and  cold)   and  osteomyelitis  is  threefold: 

1.  Pyogenic  bacteria  which  have  gained  access  to  the  blood  stream 
are  apt  to  be  deposited  where  the  tissues  are  injured  (locus  niinoris 
resistentia^). 

2.  The  trauma  may  injure  the  tissues  in  which  bacteria  have  already 
been  deposited,  and  so  reduce  their  natural  resistance  that  the  bacteria 
may  multiply  and  invade  the  tissues. 

3.  The  trauma  may  rupture  the  connective  tissue  or  bony  capsule 
which  surrounds  some  old  focus. 

The  age  at  which  the  disease  develops  and  the  position  of  the  focus 
differ.  The  greatest  number  of  eases  develop  between  the  eighth  and 
seventeenth  years.  The  disease  rarely  develops  after  the  twenty-fifth 
year.  According  to  Ilaaga  59  per  cent  of  the  cases  occur  in  the  second 
decennium,  9  per  cent  in  the  third,  2.5  per  cent  in  the  fourth,  and  2 
per  cent  in  the  fifth. 

Animal  experiments  coincide  with  clinical  experience  as  to  the  age 
in  which  osteomyelitis  is  most  frequent.  AVhile  young  animals  after 
intravenous  injections  of  staphylococci  develop  suppurating  foci  in  bone 
and  some  of  the  other  tissues,  older  animals  develop  a  suppnrative  ar- 
thritis, never  intraosseal,  and  only  rarely  periosteal  foci  (Rodet,  Lexer). 

^I'his  difference  depends  upon  the  greater  vascularity  of  young  grow- 
ing bone  and  the  histological  characteristics  of  the  cellular  marrow  of 
young  bone  which  differ  markedly  from  those  of  the  fatty  marrow  of 
adult  bone. 


THE   PYOGEXIC    INFECTIONS   OF   DIFFERENT   TISSUES  245 

The  more  frequent  occurrence  of  the  disease  in  country  people  is 
probahly  due  to  the  fact  that  they  are  less  cleanly  than  city  people 
(Kuester). 

Osteomyelitis  develops  most  frequently  in  the  long  hollow  bones,  and 
in  that  part  of  the  bone  in  which  the  changes  associated  with  growth 
are  most  active.  According  to  different  statistics  the  lower  end  of  the 
femur,  the  upper  end  of  the  ti])ia,  the  upper  end  of  the  humerus,  and 
the  lower  end  of  the  tibia  nuist  be  regarded  as  the  favorite  sites  for  the 
development  of  suppurating  foci.  They  are  involved  in  order  of  fre- 
quency as  given  above.  In  the  epiphysis  of  long  hollow  bones,  in  the 
short  and  flat  bones  where  tuberculosis  develops  fre(juently,  suppurative 
osteomyelitis  rarely  occurs.  JNFany  different  bones  or  different  parts  of 
the  same  bone  may  be  involved  simultaneously. 

Clinical  Forms. — Clinically  suppurative  osteomyelitis  may  be  divided 
into  acute  and  chronic  forms  with  a  number  of  complications.  Classi- 
fication based  upon  the  sequelae  and  bacterial  forms  may  also  be 
made. 

A  sudden  onset  and  severe  course  are  characteristic  of  acttf:  h.ema- 
TOGENOUS  SUPPURATIVE  OSTEOMYELITIS.  Strong,  previously  healthy  chil- 
dren or  young  adults  suddenly  present  the  sjmiptoms  of  severe  infection 
(chills  and  high  fever)  and  complain  of  a  severe  localized  pain.  If  an 
extremity  is  involved  the  pain  may  be  severe  enough  to  prevent  any 
movement.  At  first  the  patient  may  be  unable  to  indicate  accurately  the 
location  of  the  pain,  but  it  soon  becomes  localized  in  a  part  of  the  bone, 
usually  close  to  a  large  joint. 

Often  any  external  cause  is  wanting,  often  there  is  undoubted  con- 
nection with  a  trauma;  often  a  chronic  suppuration,  especially  after  a 
trauma  becomes  acute.  In  rare  cases  a  suppurative  osteomyelitis  de- 
velops at  the  seat  of  a  subcutaneous  fracture,  secondary  to  an  angina, 
which  developed  during  the  process  of  repair. 

The  fever,  accompanied  by  the  severest  general  symptoms,  is  continu- 
ous. In  the  course  of  one  or  more  days  the  affected  extremity  swells 
and  presents  slight  indistinct  redness,  soon  also  inflammatory  a?dema,  ten- 
sion of  the  skin,  fluctuation — in  short,  all  the  signs  of  a  phlegmon  of  the 
soft  tissues.  The  bene,  if  it  can  be  palpated  through  the  infiltrated  tis- 
sues, appears  to  be  thickened. 

The  subcutaneous  veins  are  prominent,  the  neighboring  lymphatic 
glands  enlarged  and  .sensitive  to  pressure.  Abnormal  mobility  of  the 
epiphysis  and  slight  dislocation  indicate  separation  of  tlie  epiphysis, 
which  occurs  in  from  twelve  to  fifteen  per  cent  of  the  cases  (Garre, 
Reisz).  This  occurs,  as  a  rule,  at  the  end  of  the  first  week,  rarely  as 
early  as  the  second  day.  The  neighboring  joints  often  become  involved 
in  the  inflammation  {vide  Complications). 
17 


246  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

A  few  days  after  the  onset  a  serous  infiltration  of  the  soft  tissues 
surrounding  the  bone,  particularly  the  intermuscular  septa,  is  found 
if  an  operation  is  performed.  The  discolored  periosteum,  which  may 
be  perforated  at  different  points,  is  raised  from  the  bone  by  pus,  and  the 
white  bone  is  surrounded  completely  or  partially  by  it.  AVhere  the  peri- 
osteum retains  its  connection  with  the  soft  tissues, 
it  is  able  to  regenerate.  Upon  closer  inspection  one 
sees  pus  discharged  from  the  large  canals  of  the 
metaphysis,  which  contain  vessels,  and  small  drops 
of  fat  floating  upon  the  surface  of  the  pus,  which 
indicate  that  the  latter  has  been  discharged  from 
the  medulla.  Pus  is  found  in  the  beginning  only 
in  that  part  of  the  medulla  adjacent  to  the  epiphy- 
FiG.    107.  —  Foci    of   g^^.^i  cartilage.     The  remaining  marrow  is  deep  red 

Staphylococci     in     .  .  ,   ,,  i     •,  j.j.         i        ^^        •  ^  j. 

THE  Neck   op   the    "^  color,  and  through  it  are  scattered  yellowish  spots 
Femur,  Intracapsu-    and  streaks.     Later  it  becomes  transformed  into  a 
YElifoYJcmLiT''''   yt^llowish  green  collection  of  pus.     Microscopically 
groups  of  cocci  are  found  in  the  pus. 
The  bones  more  rarely  involved  are  attacked  in  the  severest  multiple 
forms,  which  comprise  about  one  fifth  of  the  cases  (Garre),  in  addition 
to  the  one  usually  affected.     The  bones  become  infected  simultaneously 
from  some  primary  focus  or  secondarily  to  some  osteal  focus   (Garre). 
Sometimes  the  bones  become  involved  simultaneously  or  in  rapid  succes- 
sion, sometimes  after  long  intervals.     Sometimes  these  cases  pursue  an 
acute,    at   other   times   a    chronic    course.      Multiple   osteomyelitis,   like 
haematogenous  osteomyelitis,  is,  as  a  rule,  a  general  metastatic  infection 
with  pyogenic  micro-organisms.     It  occurs  in  children,  whose  bone  mar- 
row is  especially  susceptible  to  metastatic  inflammation. 

An  acute  haematogenous  suppurative  periostitis  is  most  frequently 
associated  with  small  suppurating  foci  in  the  cortex  of  flat  bones  and 
suppuration  in  tlie  metaphysis  of  long,  hollow  bones.  It  occurs  also  in 
adults. 

Those  cases  of  acute  osteomyelitis  in  which  the  focus  develops  in 
the  articular  ends  of  bone  have  been  placed  in  a  special  group,  because 
the  joints  are  so  frequently  involved  (W.  Miiller).  In  this  form,  which 
has  been  observed  in  the  very  young  up  to  the  fifth  year,  small  suppu- 
rating foci  exist.  They  are  situated  like  the  tuberculous  foci,  where  the 
vessels  from  the  metaphysis  or  periosteum  enter  the  epiphyseal  cartilage, 
or  in  the  femur,  where  the  vessels  from  the  ligamentum  teres,  in  the 
knee  from  the  crucial  ligaments,  enter  and  branch  (Fig.  106).  Foci 
are  found  in  the  periosteum,  cortex  and  medulla.  The  carpal  and  tarsal 
bone  may  also  be  involved  (Becker).  In  the  hip  joint  foci  are  found 
ill  llic  ii|)|)rr  aiigl(!  of  the  Y-shaped  epiphyseal  cartilage.     Staphylococci 


THE   PYOGENIC    INFECTIOxNS   OF    DIFFERENT  TISSEES 


24\ 


are  found  most  frequently  in  this  form  of  osteomyelitis,  the  streptococcus 
and  pneumoeoccus  relatively  frequently. 

Suppurative  arthritis,  or  after  extracapsular  rui)ture  pai-a-artieular 
phlegmon,  are  the  most  prominent  clinical  features.  AVhen  the  operation 
is  performed  a  focus  is  found,  which  should  be  thorou<i:hly  removed  with 
a  sharp  spoon  to  prevent  destruction  of  the  epiphysis  and  its  cartilage 
and  to  protect  the  joint  from  subsequent  inflammation. 


Fig.  108. — Pneumococcic  Focus  in  the  In- 
ternal M.^LLEOLus,  Rupture  Through' 
THE  Epiphysis  (Nine  Months  Old 
Child). 


Fig.  109. — Pneumococcic  Focus  in  Lower 
Articul.\r  End  of  the  Femur  of  a  Child 
Nine  Months  Old.  P,  Rupture  through 
the  epiphysis;   K,  capsule  of  joints. 


Osteomyelitis  and  periostitis  serosa  (albuminosa  of  Oilier,  non- 
purulenta  of  Schlange)  is  a  rare  form,  which  develops  most  frequently 
in  the  femur  and  is  produced  by  the  yellow  and  white  staphyloeoceus 
and  streptococcus.  After  a  mild  but  acute  onset  it  often  pursues  a  chronic 
course  and  leads  to  the  formation  of  large  periosteal  abscesses  and  sup- 
purating foci  in  bone  and  sequestra.  A  serous  or  mucoid  exudate  is 
found  instead  of  pus,  and  it  differs  in  this  way  from  the  suppurative 
form.  This  form  has  been  classified  by  Schlange  with  acute  osteo- 
myelitis because  staphylococci  have  been  demonstrated  in  the  exudate. 
The  inflammatory  reaction  is  not  so  severe,  however,  as  only  a  serous 
exudate  is  formed.  According  to  Vollert  and  Garre  it  is  possible  that 
the  pus,  previously  formed,  may  have  undergone  a  mucoid  degenera- 
tion. An  exudate  occurring  in  periostitis,  which  is  surrounded  by  a 
thick  resistant  membrane,  may  resemble  a  cyst  (periosteal  ganglion,  or 
if  occurring  on  the  skull,  it  may  be  mistaken  for  a  meningocele,  Schrank). 
The  superficial  necrosis  of  bone  and  the  demonstration  of  pyogenic 
bacteria  make  certain  the  diagnosis. 

Inflammation  of  the  joints  is  the  most  important  coiiq)lication  of 
acute  suppurative   osteomyelitis.      The  joints  may   become  infected   in 


248 


WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 


-S 


three  ways.  The  rupture  of  a  suppurating  focus  through  the  articular 
end,  or  of  a  medullary  phlegmon  through  the  epiphysis  produces  an 
acute  suppurative  arthritis.  The  arthritis  may  develop  as  a  metastatic 
infection  from  a  primary  focus  or  from  the  bone  primarily  involved. 
It  is  then  accompanied  by  a  serous  or  purulent  exudate.  The  third  form 
of  arthritis  is  the  so-called  sympathetic.  A  serous  exudate,  which  appar- 
ently is  produced  by  the  toxins,  de- 
velops, although  the  focus,  acute  or 
chronic,  in  the  epiphysis  is  complete- 
ly encapsulated.  This  form  of  arthri- 
tis may  present  the  clinical  features 
of  an  intermittent  hydrops. 

When  the  exudate  is  large,  the 
capsule  may  become  greatly  distended 
and  subluxation  occur. 

Aspiration  and  immobilization  of 
the  joint,  as  a  rule,  control  the  ar- 
thritis, accompanied  by  the  formation 
of  large  serous  exudates.  When,  how- 
ever, the  exudate  is  purulent,  the 
joint  must  be  incised  and  drained 
immediately  in  order  to  retain  good 
function.  Resection  of  the  joint  miist 
be  considered  when  the  epiphysis  and 
articular  cartilage  are  destroyed  by 
the  rupture  of  a  medullary  phleg- 
mon (Fig.  Ill) .  Pathological  changes 
in  the  articular  cartilage  produce  ad- 
hesions and  anchylosis  {vide  Diseases 
of  Joints). 

The  most  dangerous  complica- 
tion  is  GENERAL   INFECTION.      If   in   a 

few  days  a  fatal  blood  infection  de- 
velops, in  addition  to  the  infection 
of  one  or  more  bones,  it  is  impossible 
to  say  whether  the  general  infection 
is  secondary  to  the  infection  of  the 
bone  or  whether  the  bone  infection 
has  occuj-red  in  the  course  of  the  gen- 
eral infection,  hi  thes(>  cases  no  pus 
is   found    in   tlie   inflamed   bones,   but 

only  li;i'iii(iitli;mi('  foci  scattcied  throughout  a  hyperieniic  marrow  (acute 

liaMiiorrliagic  osteomyelitis). 


iT 


-IT 


a. 

Fig.  110.  Severe  O.steomyklitis  of 
THK  FEMun  IN  A  Child  Nink  Weeks 
Old,  Caused  by  Streptococci; 
Three  Weeks  After  the  liEcm- 
Nmo  OF  THE  Disease.  A',  Center  of 
OKsification;  //,  suppunitiiiK  focus;  Ci, 
internal  eondyle;  P,  ix-rforation ;  W , 
peri()st(!al  bone  formation;  >S',  si^cjues- 
tration. 


THE    PYOGENIC    INFECTIONS   OF    DIFFERENT   TISSUES 


249 


jNIt'tastatic.  sii[)ptii'a1  icii    in   (lie  scfous  cavities  and   joints  and   j)uru- 
lent  foci  in  the  or«^ans  and  nniscle.s  gives  to  this  form  of  osteomyelitis 
the  picture  of   a   aeiieral  metastatic  infection.     As  in   multiple   osteo- 
myelitis,  the   metastases   may   develop   sinniltane- 
onsly    from    some    primary    focus    or    an    osteal 
focuis. 

Other  complications  depend  upon  the  position 
of  the  bones  involved.  An  empyema  may  develop 
from  an  osteomyelitis  of  the  bones  of  the  thorax 
or  vertebrae. 

The  severest  cases,  in  which  the  symptoms  of 
a  general  infection  are  most  prominent,  may  end 
fatally  vvuthin  a  week  (the  typhus  of  bone  of 
French  authors). 

As  a  rule,  the  fever  and  general  symptoms 
subside  as  soon  as  the  bone  is  opened  and  drained 
or  the  pus  is  discharged  spontaneously.  The  mild 
subacute  cases  subside  spontaneously  after  a  few  Fig.  in 
days,  as  the  infection  is  encapsulated.  Acute 
osteomyelitis  should  always,  however,  be  regarded 
as  a  grave  disease.  Metastatic  and  general  in- 
fection and  complications  of  all  sorts  threaten  the 
life  of  the  patient,  the  destruction  of  the  diseased 
bone,  and  the  function  of  the  joint. 

In  the  acute  febrile  stage  and  in  the  febrile  relapses  bacteria  may 
be  cultivated  from  the  blood  (Garre,  Sanger,  von  Eiselberg,  Canon, 
Lexer).  The  prognosis  is  bad,  if  the  blood  infection  persists  for  some 
days  after  the  focus  has  been  opened  and  drained.  Yet  recovery  has 
occurred  in  cases  in  which  the  bacteria  have  persisted  in  the  blood  for 
weeks  (Lexer). 

Diagnosis.— The  acute  violent  onset  with  the  symptoms  of  genei-al 
infection  and  the  symptoms  of  local  inflannnation  are  important  in  mak- 
ing the  diagnosis  of  acute  suppurative  osteomyelitis.  The  diagnosis  is 
not  difficult  if  the  local  symptoms  are  found  in  bones,  which  are  fre- 
quently involved,  and  if  the  inflammatory  exudate  in  soft  tissues  can 
be  traced  to  the  bone  and  a  direct  wound  infection  or  lyinphangitic 
abscess  can  be  excluded.  Frequently  a  felon,  a  furuncle,  an  inflamed 
fissure  or  wound  (e.  g.,  scalp  wound),  an  eczema,  a  scratch,  a  tonsillar 
abscess  or  an  otitis  media  affords  the  infection  atrium. 

Osteomyelitis  is  most  frequently  confused  with  deep  lymphangitis 
and  lymphangitic  abscess,  especially  if  these  develop  in  parts  (popliteal 
fossa,  Scarpa's  triangle,  and  internal  bicipital  sulcus),  which  are  fre- 
quently secondarily  involved  in  osteomyelitis,   and  with  large  h«ma- 


sui'pukative 
Inflammation  of  the 
Elbow  Joint  Second- 
ary   TO    OSTKOMYELITIS 

OF  the  Ulna.  Articu- 
lar cartilage  of  the  fossa 
semilunaris  destroyed 
and  fibrillated. 


250  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

togenous  muscle  abscesses,  'i'lie  incision  which  is  necessary  in  the  treat- 
ment makes  the  differential  diagnosis  possible.  If  the  periosteum  is 
firmly  attached  to  the  bone,  the  inflammation  did  not  develop  in  the 
latter. 

The  treatment  of  acute  suppurative  osteomyelitis  should  protect  the 
patient  from  general  infection  and  limit  the  necrosis  of  the  bone.  The 
earlier  the  focus  is  opened,  so  nuich  the  better  will  both  indications 
be  met. 

The  incision  should  be  made  slowly,  under  general  anaesthesia, 
through  the  intermuscular  septa  to  the  surface  of  the  bone.  If  possible, 
artificial  ischa?mia  should  be  employed,  so  that  nerves,  tendons,  and 
blood  vessels  may  be  avoided.  The  yellowish  discolored  periosteum, 
raised  from  the  bone,  should  be  incised ;  the  extent  of  the  incision  de- 
pending upon  the  extent  of  the  suppuration.  If  the  subperiosteal  pus 
contains  fat  drops  and  is  discharged  from  the  bone  the  medullary  cav- 
ity and  the  spongy  tissue  of  the  metaphysis  should  be  opened.  The 
compact  bone  should  be  removed  by  a  chisel,  and  the  entire  suppurating 
focus  exposed.  The  operator  should  avoid  injuring  the  capsule  of  the 
joint,  fracturing  thin  bone,  and  separating  the  loosened  epiphysis.  If 
the  suppuration  has  extended  to  the  epiph.ysis  the  articular  cartilage 
should  be  spared.  After  the  pus  in  the  medulla  and  spongy  bone  has 
been  removed  by  sponges  or  a  sharp  spoon  the  cavity  in  the  bone  and 
the  wound  should  be  tamponed  with  iodoform  gauze. 

The  general  rules  already  given  should  be  followed  in  applying  the 
dressing,  which  should  hold  the  fragments  in  apposition  if  the  epiphysis 
has  been  separated,  and  in  the  after-treatment,  which  will  be  required  for 
from  three  to  five  months. 

Frequently  small  sequestra  are  extruded  Avhile  the  bone  cavity  and 
the  wound  are  closing  by  granulation  tissue  and  the  periosteum  is  form- 
ing new  bone.  Apparently  after  early  operation  the  greater  part  of 
the  remaining  bone  i-epaii's  and  contributes  to  later  growth.  Incision 
of  the  absce.ss  of  the  soft  tissues  without  opening  of  the  bone  as  well 
as  drilling  the  latter  at  a  number  of  different  points  is  not  enough. 
These  methods  of  treatment  do  not  pi-ovide  f(^r  a  free  discharge  of  pus 
from  the  bone.  They  favor  and  cause  chronic  suppuration,  extensive 
necrosis,  rupture  into  the  joint,  acute  relapses,  etc. 

The  complete  removal  of  Ihe  diseased  part  must  be  considered,  if 
the  epiphysis  is  necrotic,  or  if  the  shaft  of  a  long  bone  is  separated 
at  both  epiphyseal  cartilages,  is  surrounded  by  pus,  and  no  longer 
connected  with  living  tissues.  This  occurs  in  the  humerus,  ulna,  fibula, 
most  fre((uently  in  the  tibia  and  fibula  of  small  children.  In  spite  of  such 
an  extensive  necrosis  as  above  mentioned,  the  periosteum  is  able  to  form 
new  bone,  and  is  aided  by  isolated  periosteal  rests  and  the  surrounding 


THE   PYOGExNIC    INFECTIONS   OF   DIFFERENT   TISSUES 


251 


connective  tissue.  It  is  necessary  to  resect  the  infiltrated  parts  in  flat 
bones  (ilium,  scapula,  ribs).  In  the  skull  bones  it  is  often  necessary 
to  trephine,  in  addition  to  chiseling  away  the  diploii,  in  order  to  provide 
drainage  for  subdural  abscesses. 

In  the  severest  forms  of  osteomyelitis  of  the  long  hollow  bones,  ampu- 
tation or  disarticulation  may  be  necessary  in  order  to  overcome  the  gen- 
eral infection.  This  is  of  advantage  only  Avhen  the  infection  in  the  bone 
is  not  localized. 

Chronic  suppurative  osteomyeuitis  (osteomyelitis  chronica  puru- 
lenta)  develops  from  the  acute  form  and  also  occurs  as  an  independent 
form.  It  follows  open  injuries  of  bone,  periosteal  suppuration,  inflam- 
matory processes  ab(mt  bone  (e.g.,  varicose  ulcers),  and  hu'iiiatogenous 
infections. 

If  the  acute  stage  of  an  osteomyelitis  has  subsided  spontaneously 
after  rupture  and  discharge  of  the  pus,  or  if  the  pus  has  been  dis- 
charged after  incision  of  the  soft  tissues,  the 
necrotic  bone  maintains  an  inflammation,  which 
in  long,  hollow  bones  may  persist  for  a  half  year 
or  longer.  This  inflammation  may  separate  or 
rarely  digest  the  dead  bone  or  produce  osteo- 
plastic changes.  During  all  this  time  there  is  no 
trouble  to  speak  of,  unless  the  neighboring  joint 
becomes  inflamed  or  the  epiphysis  separates. 

From  time  to  time  the  fistula  leading  to  the 
dead  bone  closes,  and  then  the  patient  complains 
of  throbbing  pain  in  the  bone,  accompanied  by 
fever,  until  the  pus  is  discharged  again.  The 
bone  is  irregularly  expanded,  sometimes  its  entire 
circumference  is  involved,  at  other  times  only 
limited  areas.  When  the  patient  comes  to  the 
physician  an  inflanniiatory  infiltration  with  red- 
ness of  the  skin  and  deep  fluctuation  may  be 
present.  The  opening  of  the  fistula  (if  present) 
is  surrounded  by  luxuriant  granulations,  and  is 
not  cori'oded,  as  in  tuberculosis.  When  the  pus 
is  discharged  small  sequestra  may  be  extruded. 
A  larger,  pointed  sequestrum,  which  the  patient 
attempts  to  remove,  may  be  caught  in  the  fistula. 
Neighboring  vessels  are  sometimes  injured  in 
this  way. 

A  severe,  acute  progressive  suppuration  of  the  bone,  accompanied 
by  a  phlegmon  of  the  soft  tissues  and  high  fever,  follows,  as  a  rule, 
an  injury  of  the  chronically  inflamed  bone.     The  cocci,  which  have  re- 


FiG.    112. — Centuai-   Se- 

QUESTHUM  IN  THE  L<1W- 

ER  Third  of  the  Ra- 
dius OP'  Man  Fifty 
Years  of  Age.  The  in- 
volucrum  surroumliiig 
the  dead  bone  is  tliick. 
Gradual  enlargement  of 
the  bone  for  some  years. 
Never  acute  inflanuna- 
tion  and  rupture.  Few 
sj'inptoms. 


252  WOUND    INFECTIONS   PRODUCED   BY    BACTERIA 

niained  in  the  granulation  tissue  or  scar  for  years  without  doing  any 
harm,  pass  through  the  ruptured  protecting  capsule,  invade  the  tissues 
again,  and  are  absorbed. 

The  independent  chronic  forms  have  frequently  a  short,  but  not 
marked  acute  stage,  which  is  often  overlooked  or  forgotten.  It  occurs 
in  the  young  as  a  febrile  disease,  associated  with  pain  and  swelling 
of  one  or  more  bones,  which  subside  after  a  few  days  without  the 
discharge  of  pus.  After  many  years,  even  after  full  growth  has  been 
attained,  pain  develops  in  the  area,  which  has  always  been  somewhat 
expanded,  but  is  now  plainly  thickened.  This  bony  thickening,  which 
may  gradually  become  quite  large,  involves  most  frequently  the  ends 
(junction  of  metaphysis  and  epiphysis)  of  long  bones,  and  not  infre- 
quently is  accompanied  by  arthritis  (suppurative  synovitis,  after  rup- 
ture of  an  osteal  focus,  or  intermittent  hydrops)  and  by  abscess  forma- 
tion in  the  soft  tissues. 

Three  principal  forms  which  frequently  pass  over  into  each  other 
may  be  ditt'erentiated : 

1.  The  central  sequestrum  surrounded  by  a  very  thick  involucrum 
with  little  or  no  suppuration   (Fig.  112). 

2.  The  bone  abscess,  which  is  found  most  frequently  in  the  metaph- 
ysis. It  varies  in  size  from  a  pea  to  a  hen's  egg,  is  lined  by  a  thick 
abscess  membrane,  and  contains  thick,  sclerotic  bone.  The  bacteria 
(both  varieties  of  the  staphylococcus)  found  in  these  abscesses  may 
remain  viable  for  twenty  or  thirty  years. 

3.  The  sclerotizing  osteomyelitis  (Garre),  which  has  an  acute  or 
subacute  onset,  but  does  not  lead  to  pus  formation,  is  to  be  regarded  as 
a  less  active  form.  The  at  times  painful,  gradually  thickening  bone, 
is  transformed  finally  into  a  solid  mass,  which,  as  in  syphilitic  hyperos- 
toses, may  encroach  upon  the  marrow  cavity.  A  large  area  or  only  the 
ends  of  the  bone  may  be  transformed  into  such  a  mass.  Very  small 
abscesses,  foci  of  granulation  tissue,  and  small  central  sequestra  are 
frequently  found  within  this  sclerotic  bony  tissue. 

Acute  exacerbations,  which  may  follow  trauma  and  other  diseases, 
are  the  dangers  of  chronic  suppurative  osteomyelitis.  Abscesses,  inflam- 
mation and  disturbance  of  the  function  of  joints  and  different  sequelae 
may  develop  even  after  long  intervals. 

The  diagnosis  of  the  chronic  form  may  be  difficult  if  other  signs  do 
not  indicate  the  nature  of  the  changes,  which  may  not  be  very  distinct 
even  in  the  Roentgen  ray  picture.  The  diagnosis  of  sarcoma,  tubercu- 
losis, gumma,  and  bone  cyst  may  be  made,  therefore  in  doulitful  cases  an 
exploratory  incision  should  be  Tuade. 

The  swelling  which  develops  insidiously  upon  the  ends  of  bones, 
near  joints,   and  upon  short  bones,  such   as   the   clavicle,    without   the 


THE   PYOGENIC   INFECTIONS  OF   DIFFERENT  TISSUES  253 


signs  of  inflammation  and  fistula  formation,  resembles  myelogenous  or 

periosteal  sarcomas.     At  first  they  develop  slowly,   after  a  time   more 

rapidly,   and   produce    pain,    functional    and    circulatory    disturbances. 

The  development  of  an  inflammatory  infiltration  and  reddening  of  the 

skin  are  the  surest  signs  of  the  inflammatory  nature  of  this  chronic 

process.    In  rare  cases  (Kocher,  Jordan)  the  swelling  is  composed  mostly 

of  granulation  tissue,  and  the  compact  bone  covering  it  is  thinned,  so 

that  a  microscopic  or  bacteriologic  examination  must  be  made  before 

it  is  possible  to  diagnose  the  nature  of  the  swelling.     Thick  ma&ses  of 

periosteal  scar  tissue,  resulting  from  previous  inflammation,  may  lead 

to  the  diagnosis  of  sarcoma  (Nasse,  A¥.  IMueller).    When  such  a  mass  is 

exposed,   small  granulating   and  suppurating   foci 

and  sequestra  will  be  found.     Chronic  epiphyseal 

foci,    especially   if   they   have   produced   a   serous 

synovitis,  may  be  mistaken  for  tuberculosis.     The 

fistulas  following  chronic  osteomyelitis  do  not  have 

the  corroded  borders  Avhich  characterize  the  tviber- 

culous.     The  pus  in  the  small  osteal  foci  is  thick 

and  mucoid,  not  caseous,  the  sequestra  jagged  and 

irregular,  not  round,  as  in  tuberculosis.    The 

swellings   of   the   diaphysis,    which   occur   in 

the   non-suppurative    sclerotizing    form,    and 

are    characterized    by    frequently    recurring    bone 

pain   and   a   chronic   course,   remind   one   of  bone 

syphilis,  especially  if  there  is  no  acute  stage. 

Bone  cysts  resemble  serous  abscesses,  which  are 
encapsulated  by  thick  connective  tissue.  The  dem- 
onstration of  bacteria  makes  a  differential  diagno- 
sis possible,  if  it  cannot  be  made  from  other  data. 

The    treatment   of    chronic    suppurative    osteo- 
myelitis consists  in  the  removal  of  the  sequestrum, 
the   exposure   and   evacuation  of  the   suppurating 
focus.     If  the  focus  is  centrally  situated  the  bone 
nuist  be  chiseled  away   (ne- 
crotomy).    One  may  figure 
upon  a  complete  separation 
of  even  large  sequestra  and 
the  development  of  a  strong 
involucrum    if    six    months 
have  passed  since  the  begin- 
ning of  the  disease. 

In  exposing  the  focus  the  periosteum   is  incised  the  length   of  the 
swelling  and  reflected  to  either  side.     The  exposed  wall  of  bone  is  tlien 


Fig.  113. — Necrosis  of  the  'Iiiiia  with  Xumerots 
Cloaca  Exposed  for  Seqitestrotomy. 


254 


WOUND   INFECTIONS   PRODUCED   BY  BACTERIA 


removed  with  a  chisel  or  gouge.  When  the  sequestrum  is  removed  the 
granulation  tissue,  pus,  and  abscess  membrane  are  removed  by  sponges 
or  the  sharp  spoon.  The  sharp  borders  of  the  bone  are  cut  away  with  a 
straight  chisel,  and  the  cavity  in  the  bone  is  then  tamponed.  Foci  and 
sequestra  about  the  epiphyseal  cartilage  must  be  followed  if  necessary 
into  the  epiphysis.  The  epiphyseal  and  articular  cartilages  and  joint 
capsule  should  not  be  injured. 

Repair  by  the  formation  of  granulation  tissue  is  slow.  Deep  fistula, 
which  extend  into  the  metaphysis,  and  which  must  be  curetted  fre- 
quently, often  remain. 

The  deep  bone  cavities  near  the  articular  ends,  which .  cannot  be 
smoothed  off  completely,  because  so  near  the  joint,  may  be  closed  most 
easily  in  the  following  way :  After  healthy  granulation  tissue  has  devel- 
oped, a  pedunculated  skin  flap  is  made  and  placed  upon  the  vivified 
granulating  surface,  or  during  the  operation  the  skin  flaps  are  so  fash- 
ioned that  after  the  removal  of  the  tampon  they  may  be  turned  into  the 

wound.  They  may  be  held  in  position 
by  dressings,  small  nails,  or  adhesive 
plaster. 

Osteoplastic  necrotomy  (Luecke,  Oi- 
lier, Bier),  in  which  a  piece  of  the  in- 
volucrum,  retaining  a  periosteal  attach- 
ment, is  used  to  fill  in  the  cavity,  has  the 
disadvantage  that  dead  spaces  form  be- 
neath the  flap  and  pus  is  retained.  The 
process  of  repair  is  not  shortened. 

A  number  of  attempts  have  been  made 
to  close  these  cavities  with  different  kinds 
of  plugs.  The  iodoform  bone  plug  intro- 
duced by  Mosetig-Moorhof,  consisting  of 
60  parts  of  iodoform  and  40  parts  each 
of  spermaceti  and  oil  of  sesame,  has  been 
the  most  successful.  It  does  not  act  as 
a  foreign  body  as  other  bone  plugs  do, 
and  does  not  produce  suppuration.  It  is 
gradually  absorbed  and  replaced  by  con- 
nective tissue  or  newly  formed  bone,  after 
the  skin,  which  was  immediately  sutured, 
has  been  healed  for  some  time. 

Tlic  most  important  sequela?  are:  Spon- 
taneous fracture  or  infraction  at  the 
point  wlietc  llic  Ix.nc  juis  been  weakened  by  the  inflammatory  process, 
'i'lic    i'lacturc   oceui's  most   fre(|uently   in  the  demarcation   zone,    where 


Fig.  114. — Incision  for  Exposure 
AND  Partial  11i;movai.  of  the 
Tibia  in  Extensive  Suppttua- 
TiVE  Osteomyelitis. 


THE   PYOGENIC   INFECTIONS  OF   DIFFERENT  TISSUES         255 


the  involiicruiii  is  poorly  developed  or  it  is  Avcakened  by  ;in  oporation, 
iu  rare  eases  also  at  the  site  of  the  seipicstnim,  whieli  is  not  suffieieiitly 
supported  by  the  involucruin.  The  fraeture  may  follow  extensive 
suppuration.  Necrotomy  should  be  performed,  and  the  fragments 
approximated  and  retained  in 
as  good  position  as  possible. 
The  repair  of  such  a  fracture 
is  slow,  pseudarthrosis  often 
cannot  be  prevented. 

Pathological  dislocation  oc- 
curs most  frequently  at  the  hip 
joint ;  subluxation  at  the  knee 
joint.  They  result  from  the 
destruction  of  the  joint  (de- 
struction-dislocation) or  from 
distention  of  the  capsule  by 
effusions  into  the  joints  (dis- 
tention-disloeation) .  Separa- 
tion of  the  rim  of  the  acetabu- 
lum, which  then  moves  upon 
the  ilium,  may  lead  to  the 
diagnosis  of  pathological  dislo- 
cation. 

Bending  may  occur  at  the 
weak  point  of  the  involucrum 
if  weight  is  borne  upon  the 
leg  or  as  the  result  of  muscu- 
lar contraction,  e.  g.,  this  bend- 
ing may  be  forward  in  the 
lower  end  of  the  femur,  dis- 
placement backward  of  the  up- 
per end  of  the  tibia  from  con- 
tracture of  the  Hexor  tendons. 
The  most  marked  deformities 
follow  separation  of  the  epiphysis,  with  subsecpient  imperfect  repair. 
These  deformities  are  also  partly  due  to  irregular  growths  resulting 
from  disease  and  destruction  of  the  epiphyseal  cartilage. 

Disturbances  of  growth  consist  of  shortening  and  lengthening  of 
the  diseased  and  neighboring  bones  (Oilier,  von  Bergmann,  Ilelferich). 
Shortening  of  the  bone  follows  the  destruction  of  the  epiphyseal  carti- 
lage, which  does  not  regenerate.  Foci  in  the  diaphysis  and  metaphysis 
may  stimulate  the  zone  in  which  growth  is  most  active,  and  ])r()duee  a 
lengthening  of  the  bone.     Either  of  these  changes,  dcpcntliug  u[)()ii  the 


Fig.  115. — RAnioFiKxinN  nr  iiii:  Hand  Fol- 
lowing Destruction  of  the  Loaveh  Ki-iph- 
YSis  OF  THE  Radius  by  a  Suppurative  Os- 
teomyelitis. 


L 


256 


WOUND    INFECTIONS   PRODUCED    BY   BACTERIA 


position  of  the  focus,  may  be  produced  experimentally  (Lexer).  These 
pathological  chano;es  occurring  in  the  bones  of  the  forearm  and  leg  may 
give  rise  to  a  number  of  deformities  (pes  valgus,  varus,  manus  radioflexa, 
genu  valgum,  varum,  etc.),  for  the  plane  of  the  joint  is  displaced  and 

deformities  of  the  rapidly  growing  bones 
(healthy  or  diseased)  result.  Moreover, 
the  healthy  bones  of  an  extremity  may  be 
increased  in  length  as  the  result  of  the 
increased  blood  supply  accompanying  the 
inflammation.  In  inflammation  of  the 
bones  of  the  leg,  the  femur  may  increase 
in  length  and  the  reverse ;  in  osteomyelitis 
of  the  bones  of  the  forearm  the  humerus 
nuiy  become  longer.  In  this  way  the  short- 
r  wm  ening  of  the  diseased  bone  is  compensated. 

bf  P^Ms>   ^W'^^^L  According  to  Oilier,  when  a  bone  of  an 

extremity  becomes  shortened,  there  is  a 
compensatory  lengthening  of  the  bone  ad- 
jacent to  it. 

Contractures  ^v\i\\  fibrinous  adhesions 
Fig.  116.— Marked  Curvature  of  r^^^\^  anchylosis  may  follow  the  iuflamma- 

THE  Tibia  Resulting  FROM  Short-  />   j^i        •    •  '  ■  •         i 

ENING  OF  THE  DISEASED  FiBULA.     t^'n  of  thc  jOHits  occurmig  lu  tho  coursc 

of  an  osteomyelitis. 

Von  Volkmann  has  designated  as  recurrent  osteomyelitis  the  form 
which  develops  after  an  interval  of  years  upon  a  completely  healed 
osteomyelitis.  The  old  area  may  be  involved,  or  a  bone  which  has  been 
perfectly  healthy.  There  is  either  the  invasion  by  bacteria,  which  have 
remained  latent  about  the  old  focus,  or  there  is  a  new  blood  infection. 
It  is  ])ossible  to  explain  in  this  way  the  development  of  inflammatory 
changes  in  old  esteomyelitic  foci  and  in  healthy  bone.  The  scar  tissue 
of  the  old  focus  may  contain  latent  bacteria,  or  it  may  be  the  locus 
miiioris  resistcntiu',  where  the  bacteria  circulating  in  the  blood  are  de- 
posited. When  the  inflammation  occurs  in  bone  not  previously  involved, 
one  cannot  exclude  a  focus  which  developed  without  symptoms  in  youth 
and  (■('iiijiiiicd  Inlcnt. 

Bacteriology. — A  classification  of  hematogenous  suppurative  osteo- 
myelitis based  upon  the  bacterial  forms  cannot,  as  a  rule,  be  made. 
The  clinical  diff'erences  between  the  inflammations  produced  by  the  dif- 
ferent bacteria  are  not  striking  enough  to  make  this  possible. 

Streptococci  produce,  according  to  our  present  knowledge,  small  cor- 
tical and  metaphyseal  foci  with  suppurative  arthritis  (especially  in  chil- 
dren) as  well  as  medullary  i^hlegmens  Avith  separation  of  the  epiphysis 
and  extensive  necrosis.     Stre])tococci  also  produce  osteitis  albuminosa, 


THE   PYOGENIC    INFECTIONS   OF   DIFFERENT  TISSUES  257 

abscess,  chronic  thickening,  and  inflammation  of  the  flat  bones.  The 
pus  is  thin,  milky,  discolored  green,  and  is  formed  in  large  quantities. 
Mixed  infections  of  staphylococci  and  streptococci  produce  severe  local 
and  general  symptoms. 

Pneumocoecic  osteomyelitis  is  more  rare.  The  foci  are  situated  in  the 
ends  of  the  bone  near  the  joints,  from  which  they  produce  suppurative 
arthritis.  The  pus  resembles  the  streptococcic  pus.  There  develops  in 
rare  cases  in  children  and  adults  during  the  course  of  ])iieunionia  peri- 
osteal and  cortical  suppuration,  and  also  suppurative  inthunmation  of 
subcutaneous  fractures  (Lexer). 

A  gonococcic  osteomyelitis  (in  the  humerus  of  an  adult)  has  been 
observed  once  by  Ullmann.  A  perichondritis  of  a  rib  has  been  observed 
by  Finger. 

The  bacterium  coli  commune  has  been  found  in  some  cases  (Klemm, 
IMauclaire)  associated  with  the  typhoid  bacillus  and  staphylococcus.  Its 
presence  is  indicated  by  foul-smelling  and  discolored  pus. 

Sehlangenhaufer  found  the  bacillus  of  pneumonia  (Priedlaender)  in 
an  extensive  osteomyelitis  in  an  adult.  There  are  also  rare  cases  of  acti- 
nomycosis in  which  the  fungus  has  been  found  in  an  osteal  focus  (Wrede, 
Fig.  142,  p.  369).  Wyss  found  an  anaerobic  bacillus  (Bacillus  halo 
septicus)  in  the  ichorous  pus  of  an  osteomyelitis  of  the  tibia. 

Typhoid  osteomyelitis  (osteomyelitis  typhosa)  developing  in  the 
course  of  or  subsequent  to  typhoid  fever  demands  a  separate  considera- 
tion. It  develops,  as  a  rule,  in  from  the  fourth  to  the  sixth  week  of  the 
disease;  sometimes  after  many  years.  It  is  caused  by  the  typhoid  l)acil- 
lus,  frequently  associated  with  the  ordinary  pyogenic  bacteria,  which  pass 
from  the  intestinal  ulcers  into  the  blood  and  are  finally  deposited  in  the 
bones.  Its  onset  is  indicated  by  a  rise  of  temperature  and  pain  in  the 
bone  involved.  Trauma  is  frecpiently  the  pre- 
disposing cause.  The  resulting  abscess,  which 
is  often  very  large,  contains,  if  there  is  no  sec- 
ondary infection,  a  yellowish-brown,  rust-col- 
ored fluid,  the  so-called  typhoid  pus,  which  may 

be  sterile.    It  does  not  difl:'er  from  ordinary  pus       Fig.  ii7.— Typhoid  Focus 
,  .     „     ,.  -.1     .,  •  ;  IN    A    Costal    Carti- 

if  secondary  mfection  with  the  pyogenic  cocci  ^^^^ 

occurs. 

When  the  abscess  ruptures,  external  suppurating  fistulfe,  which  are 
maintained  by  small  granulating  and  necrotic  foci,  are  produced.  These 
fistukp,  which  are  very  resistant  to  treatment,  remind  one  of  tuberculous 
fistuke. 

Typhoid  osteomyelitis  develops  most  frequently  in  the  ribs.  The 
foci  are  situated  in  the  costal  cartilages  close  to  their  articulation  with 
the  ribs  or  in  the  latter,  in  which  are  found  small  total  sequestra  sur- 


258  WOUND    INFECTIONS   PRODUCED   BY    BACTERIA 

rounded  by  a  thick  granulation  tissue  and  a  thin  invohicrum.  Cor- 
tical and  central  foci  develop  in  the  tibia;  the  involvement  of  other 
bones  (pelvic  and  skull  bones,  clavicle,  sternum,  humerus,  femur,  ver- 
tebKF,  spondylitis  typhosa,  Quincke)  is  rare.  The  osteomyelitis  has  an 
acute  stage,  and  then  pursues  a  chronic  course.  It  is  not  rare  for  mul- 
tiple foci  to  develop.  The  inflammation  remains  localized  and  there  is 
but  little  reactive  bony  growth.  If  the  disease  resembles  acute  sup- 
purative osteomyelitis  there  is  either  a  mixed  infection  or  infection 
with  the  staphylococcus  or  streptococcus  alone  {vide  Secondary  Osteo- 
myelitis). 

Ebermaier  and  Quincke  made  the  important  observation  that  typhoid 
bacilli  are  found  as  regularly,  and  almost  in  as  large  number,  in  the 
red  bone  marrow  as  in  the  spleen  of  patients  dying  of  typhoid  fever. 
They  remain  viable  for  a  long  time,  as  they  have  been  found  in  osteal 
foci  six  to  seven  years  after  convalescence  from  typhoid  fever  (Sultan, 
Buschke,  and  others).  According  to  Ponfick  these  bacteria  produce 
slight  but  general  alterations  in  the  bony  system,  partly  periosteal  thick- 
ening, partly  superficial  caries.  These  findings  make  clear  the  relation 
existing  between  trauma  and  typhoid  osteomyelitis.  Pyogenic  cocci  may 
also  pass  through  the  diseased  intestinal  mucous  membrane,  enter  the 
blood,  and  cause  inflammation  of  bone  even  in  adults,  for  the  resistance 
of  the  bone  marrow  has  been  reduced  by  the  typhoid  infection. 

Suppurative  inflammation  of  bone  following  infectious  diseases  is 
called  secondary  osteomyelitis. 

Before  such  an  osteomyelitis  develops,  there  must  be  a  localization 
of  the  specific  organisms  in  bone.  In  the  metapneumonic  osteomyelitis 
pneumococci  and  streptococci  are  found.  Infection  atria  are  provided 
in  the  course  of  infectious  diseases  for  the  ordinary  pyogenic  bacteria, 
and  the  resistance  of  the  bone  marrow  is  also  probably  reduced,  and  is 
therefore  more  susceptible  to  infection.  This  form  of  osteomyelitis  de- 
velops in  the  course  of  or  subsequent  to  typhoid  fever,  pneumonia, 
measles,  scarlet  fever,  diphtheria,  influenza,  and  smallpox. 

PiiosPiiOKUK  NECROSIS  is  also  a  secondary  but  not  a  pure  suppurative 
osteomyelitis.  Chronic  phosphorus  poisoning,  which  follows  the  inhala- 
tion of  pliosphoi'us  fumes  in  the  preparation  of  crystalline  phosphorus 
and  the  manufacture  of  phosphorus  matches,  is  associated  with  changes 
in  the  bones. 

Some  ))ost-mortem  exaTninati(ms  have  d(>monstrated  an  ossifying 
process  (phosphorus  periostitis  and  sclerosis),  while  clinical  observations 
have  (IciiHiiislralcd  abiioriiuil  softness  and  fragility  of  the  bones.  Some 
patients  have  had  iimltii)h'  fractures  (a  case  reported  by  Ilaeckel  suf- 
fered thirteen  fractures  in  sixteen  yeai's).  The  nature  of  these  changes, 
especially  those  occurring  in  the  jaws,  is  not  exactly  known.     There 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT  TISSUES 


259 


appears  to  be  some  direct  relation  to  the  phosplioriis  fumes  which  are 
inhaled. 

Continued  feeding  of  small  amounts  of  phosphorus  produces  in  young 
animals  an  osteosclerosis  (Wegner).  On  the  other  hand,  a  direct  action 
upon  exposed  bony  surfaces  cannot  be  (iemousti-atcd  (von  Stubenraucli). 


s'"'^ 


:'^  i: '. 


Fig.  118. — Phosphorus  Necrosis  of  the  Mandible  After  Haeckkt..  Removed  from  a 
woman  twenty-five  years  of  age.  At  k,  beginning  line  of  demarcation,  at  I  a  cloaca  in 
the  depths  of  which  a  cortical  sequestrum  may  bo  seen.  Osteophytes  cover  the  surface 
of  the  bone. 


The  most  important  changes  occur  in  the  mandi])le  nnd  maxilla,  espe- 
cially in  people  who  are  engaged  in  the  manufacture  of  matches.  These 
changes  were  first  described  by  Lorinser  in  1845. 

The  first  changes,  which  sometimes  consist  of  greater  fragility  of  the 
jawbones,  sometimes  of  thickening  and  sclerosis,  develop  without  symp- 
toms and  insidiously.  The  symptoms  of  the  disease,  which  is  to  be  re- 
garded as  a  secondary  suppurative  or  sanious  osteomyelitis,  developing  in 
bone  already  altered  by  phosphorus  fumes,  begin  with  an  inflammation 
of  the  gums  and  periosteum.  This  inflammation  is  caused  by  the  differ- 
ent pyogenic  and  putrefactive  bacteria  of  the  mouth  cavity  which  gain 
access  from  carious  teeth,  small  ulcers,  and  injuries  to  the  gums  and 
periosteum.  Some  of  the  teeth  become  loosened,  yet  there  is  no  im- 
provement, as  in  the  ordinary  periostitis  alveolaris,  when  they  are 
extracted.     Pain  and  swelling  increase,  the  floor  of  the  mouth  and  the 


260  WOUND   INFECTIOxNS   PRODUCED   BY   BACTERIA 

cheeks  become  infiltrated.  Later  suppuration  occurs,  and  fistulaa  are 
formed  from  which  is  discharged  foul-smelling  pus.  Other  teeth  become 
loosened,  the  gums  and  the  periosteum  are  raised  from  the  bone  by  a 
layer  of  pus,  and  the  surface  of  the  bone  is  exposed.  A  large  part  of 
the  bone  involved  may  be  destroyed  by  the  chronic  progressive  inflam- 
mation ;  the  entire  mandible  may  become  necrotic  in  from  six  to  nine 
months.  The  remaining  healthy  periosteum  forms  a  thick  involucrum. 
The  sequestrum,  the  edges  of  which  become  osteoporotic,  separates  slowly. 
In  extensive  necrosis  two  to  three  years  are  required  for  the  separation 
of  the  sequestrum.  Healing  occurs  after  the  sequestrum  is  extracted. 
In  the  meantime  anchylosis  of  the  jaw,  disturbances  of  digestion,  due  to 
the  swallowing  of  pus,  poor  nutrition,  pain  in  the  entire  jaw,  and  other 
symptoms  which  are  frequently  accompanied  by  fever  develop.  The 
patient  becomes  weaker,  and  complications  such  as  meningitis,  general 
infection,  and  i)neumonia  may  prove  fatal.  Death  occurs  in  about  one 
half  of  the  cases. 

The  mandible  is  involved  about  nine  times  more  frequently  than  the 
maxilla,  and  the  necrosis  occurring  in  the  former  is  much  more  extensive. 

The  treatment  is  prophylactic  and  operative.  The  workrooms  in 
match  factories  should  be  well  ventilated;  the  mouth  hygiene  should  be 
good ;  employees  should  not  be  allowed  to  eat  or  drink  in  the  workroom ; 
and  the  hands  should  be  carefully  washed  after  work.  The  teeth  of  the 
employees  should  be  inspected  frequently  by  a  dentist,  and  no  person 
employed  Avho  has  bad  teeth.  By  proper  ventihition  of  the  factory  and 
proper  care  of  the  teeth  of  the  employees,  the  largest  match  company  in 
America,  the  Diamond  Match  Co.,  has  practically  eliminated  the  disease. 
The  operative  treatment  consists  of  early  and  extensive  subperiosteal 
resection  of  the  diseased  bone. 

After  the  pei'iosteum  and  the  osteophytes  attached  to  it  are  sepa- 
rated, all  the  diseased  bane  is  removed,  the  resection  being  carried  into 
healthy  tissues.  Siiuill  partial  resections  of  the  alveolar  process  should 
not  be  made,  but  the  middle  piece,  a  half  of  the  mandible,  or  the  entire 
bone  should  be  removed,  depending  upon  the  extent  of  the  pathological 
changes,  and  the  same  treatment  should  be  employed  in  necrosis  of  the 
maxilla  (Riedcl,  llaeckel).  Suppuration  ceases  and  repaii-  follows  after 
conii)lete  removal  of  the  diseased  bone.  The  periosteum  regenerates  bone 
so  rapidly  that  good  functional  and  cosmetic  results  are  soon  obtained, 
even  after  a  total  resection. 

LiTEHATURK. — .1 .  Bccker  (W.  Miiller).  Ueber  einen  iingewohnlichen  Ausgang  der 
akuten  Osteomyelitis.  Dcvitschc  Zeitschr.  f.  Chir.,  Bd.  5.),  1!)00,  p.  577. — v.  Bergmann. 
Uebcr  die  piithol.  Liingszunuhme  der  Knochen.  Petersb^  med.  Zeitschr.,  Bd.  20. — 
Brnasch.  Ueber  pathol.  Wachstum  der  Extremitatenknochen  iin  Oefolge  akuter 
Osteomyelitis.     I.-D.    Berlin,    18!)7. — Dniorhowskl    und    Janowski.      Ueber    Eifcrung 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT   TISSUES         261 

erregende  Wirkung  ties  TJ^lhusb:lzillus.  Zieglers  Beitr.  z.  path.  Anat.,  Bd.  17,  1805, 
p.  221. — Emlerloi.  llistol.  Untcrsut-hungen  bci  experini.  erzeiigter  Osteomyelitis. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  52,  1809,  p.  203. — Franke.  T'ebcr  einige  chir.  wichtige 
Komplikationen  und  Nachkrunkheiten  der  Influenza.  Chir.-Kongr.  Verhandl.,  1890, 
II,  p.  400. — Funke.  Beitr.  zur  Kenntnis  der  akuten  Osteomyehtis.  Arch.  f.  klin. 
Chir.,  Bd.  50,  1805,  p.  462. — Gangolphe.  Maladies  des  os,  Paris,  1804. — Gam'.  Ueber 
besondere  Formen  und  Folgezustiinile  der  akuten  inf.  Osteomyelitis.  Beitr.  z.  klin. 
Chir.,  Bd.  10,  1803,  p.  241. — Gelimky.  Eirie  Skelettdurchleuchtung  bei  einem  Fall  von 
Pyamie.  Fortschr.  auf  d.  Geb.  d.  Rontgenstrahlen,  Bd.  0. — Haeckel.  Die  Phospliorne- 
krose.  Arch.  f.  klin.  Chir.,  Bd.  30,  1880,  p.  5'yr>. — Heljcrkh.  ITeber  die  nach  Nekrose 
an  der  Diaphyse  der  langen  E.xtremitiitenknochen  auftretenden  St()rungen  ini  Liingen- 
■wachstum  ilerselben.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  10,  1878,  p.  324. — Iliidlnwsir. 
Typhose  Erkrankungen  der  Knochen  und  Gelenke.  Saminelref.  Zentralbl.  f.  Grcnz- 
gebiete,   1901,  p.  417. — Jordan.     Die  akute  Osteomyelitis.     Beitr.  z.  klin.  Chir.,  Bd. 

10,  1803,  p.  587; — -Ueber  atypische  Formen  der  akuten  Osteomj-elitis.  II  id.,  Bd. 
15,  1806,  p.  457. — Kocher  und  Tavel.  Chirurgische  Infektionskrankheiten,  1805. — 
Kiister.     Ueber   Friihoperationen   bei    Osteomyelitis.     Chir.-Kongr.    Verhandl.,    1804, 

11,  p.  307. — Lexer.  1.  Zur  experim.  Erzeugung  osteomyelitischer  Herde.  Arch.  f. 
klin.  Chir.,  Bd.  48,  1804,  p.  181;  2.  Osteomyelitisexperimente  mit  einem  spontan  beim 
Kaninchen  vorkommenden  Eitererreger.  Ibid.,  Bd.  52,  1806,  p.  576;  3.  Experi- 
mente  iiber  Osteomyelitis.  Ibid.,  Bd.  53,  1806,  p.  266;  4.  Die  Aetiologie  und  die 
Mikroorganismen  tier  akuten  Osteomyelitis,  v.  Volkmanns  Samml.  klin.  Vortr.,  N.  F., 
173,  1807;  5.  Zur  Kenntnis  der  Streptokokken-  uml  Pneumokokkenosteomyelitis. 
Arch.  f.  klin.  Chir.,  Bd.  57,  1808,  p.  870;  6.  Die  Entstehung  entzvmdlicher  Knochenherde 
u.  ihre  Beziehung  zu  den  Arterienverzweigungen  der  Knochen.  Ibid.,  Bd.  71,  1903, 
p.  1 ;  7.  Weitere  Untersuchungen  iiber  Knochenarterien  u.  ihre  Bedeutung  f.  Krankh. 
Vorgiinge.  Ibid.,Bd.  73,  1004,  p.  481;  8.  Untersuchungen  iiber  Knochenarterien  u.  s. 
w.  Berlin,  Hirschwald,  1004. — v.  Mangoldt.  Zur  Behandlung  der  Knochenhohlen  in 
der  Tibia.  Arch.  f.  klin.  Chir.,  Bd.  60,  1903,  p.  82.— v.  Mosetig-Moorhof.  Die  Jo- 
doformknochenplombe.  Zentralbl.  f.  Chir.,  1903,  p.  433; — Erfahrungen  mit  der 
Jodoformknochenplombe.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  71,  1004,  p.  410. — Xasse. 
Chirurgische  Krankheiten  der  unteren  Extremitaten.  Deutsche  Chirurgie. — Oilier. 
Traite  experimental  et  clinique  de  la  regeneration  des  os  et  de  la  protkiction  artificielle 
du  tissue  osseux.  Paris,  1867. — Perez.  Die  Influenza  in  chirurgischer  Beziehung. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  63,  1002,  p.  460. — Reiss.  Klinische  Beobachtungen 
iiber  Osteomyelitis  der  langen  Rohrenknochen,  besonders  in  Bezug  auf  die  Epiphysen- 
knorpelfuge  und  die  begleitenden  Gelenkaffektionen.  Arbeitcn  aus  v.  Bergmanns 
Khnik  Berlin,  Bd.  15,  1001. — RegnauU.  De  la  longeur  relative  des  os.  Bull,  et  mem. 
de  la  societe  anatom.  de  Paris,  1000,  No.  5. — Riedel.  Ueber  Phosphornekrose.  Chir.- 
Kongr.  Verhandl.,  1S96,  II,  p.  485. — -Rieffel  et  Mauclaire.  Maladies  des  os.  Traite  de 
chirurgie,  le  Dentu  et  Delbet,  Paris,  1806. —  Rocselcr.  Beitr.  zur  Osteomyelitis  mit 
besonderer  Beriicksichtigung  der  Therapie  uml  der  Heilerfolge.  v.  Volkmanns  Samml. 
klin.  Vortr.,  N.  F.,  243. — -Schanz.  Ueber  Spondylitis  typhosa.  Arch.  f.  klin.  Chir.,  Bd. 
61,  1000,  p.  103. — Schlagenhaufer.  Osteomyelitis  durch  Bacillus  pneumoniae.  Zentral- 
bl. fiir  Bakteriol.,  Bd.  31,  1002,  p.  73. — Schlange.  Ueber  einige  seltenere  Knochen- 
affektionen.  Arch.  f.  klin.  Chir.,  Bd.  36,  1887,  p.  97.— M.  B.  Schmidt.  Akute  eiterige 
Osteomyelitis.  Ergebn.  d.  allg.  Path.  Lubarsch-Ostertag,  January  5,  Wiesbailen,  1000, 
p.  056. — Schrank.  Ueber  einen  Fall  von  seriiser  Osteomyelitis  am  liinterhaupte, 
der  eine  Meningocele  vortauschte.  Berl.  klin.  Wochenschr.,  1002,  p.  780. — Schuchardt. 
Die  Krankheiten  der  Knochen  u.  Gelenke.  Deutsche  Chir.,  1800. — Silbcnnark.  Ueber 
die  gewebl.  Verantlerungen  nach  Plombierung  von  Knochenhohlen.  Deutsche  Zeitschr. 
f.  Chir.,  Bd.  75,  1004,  p.  200. — v.  Stubenrauch.     Die  Lehre  von  der  Phosphornekrose. 

18 


262  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

V.  Volkmanns  Samml.  klin.  Vortr.,  N.  F.,  303. — Trcndel.  Beitr.  z.  Kenntnis  der  akut. 
infekt.  Osteomyelitis.  Beitr.  z.  klin.  Chir.,  Bd.  41,  1904,  p.  607. — Ullmann.  Osteomye- 
litis gonorrhoica.  Wien.  med.  Presse,  1900. — v.  Volkmann.  Die  Krankheiten  der 
Bewegungsorgane,  1865. — Vollert.  Ueber  die  sogen.  Periostitis  albuminosa.  v. 
Volkmanns  Samml.  klin.  Vortr.,  352,  1890. — Wegner.  Der  Einfluss  des  Phosphors 
auf  den  Organismus.  Virchows  Arch.,  Bd.  55,  1872,  p.  11. — Weichselbaum.  Verander- 
ungen  der  Knochen  bei  den  akuten  Infektionskrankheiten.  Verhandl.  der  Gesellsch. 
deutscher  Naturforscher,  1894,  Wien. — Wrede.  Hiimatogene  Osteomyelitis  durch 
Aktinomyces.  Chir.-Kongr.  Verhandl.,  1906. — Wyss.  Ueber  einen  neuen  anaerob. 
path.  Bac.     Mitteil.  a.  d.  Grenzgeb.,  Bd.  1904,  p.  199. 

(f)     PYOGENIC   INFECTIONS   OF   JOINTS 

Etiology. — Primary  infection  of  a  joint  follows  gunshot,  contused 
and  punctured  wounds,  the  penetration  of  foreign  bodies  (needle,  nail, 
pieces  of  glass  or  steel),  compound  dislocations  and  fractures.  Second- 
ary infection  occurs  when  an  adjacent  phlegmon,  erysipelas,  acute  and 
chronic  suppurative  osteomyelitis  extends  to  a  joint,  or  when  a  fistula, 
resulting  from  previous  disease  of  the  joint  (e.  g.,  tuberculous  fistula), 
becomes  infected. 

Bacteriology. — Ila^matogenous  arthritis  develops  when  bacteria  are 
deposited  in  the  capillaries  of  the  synovial  membrane.  This  form  of 
arthritis  develops,  as  a  rule,  during  the  course  of  other  infections,  and 
an  injury  may  be  the  predisposing  cause.  A  multiple  serous  arthritis 
may  develop  in  the  course  of  an  endocarditis  caused  by  pyogenic  bac- 
teria, which  may  resemble  clinically  and  be  confused  with  acute  articular 
rheumatism.  Suppurative  arthritis  accompanies  especially  acute  suppu- 
rative osteomyelitis  and  the  general  pyogenic  infections.  Serous  and 
suppurative  arthritis  occurs  in  the  course  of  a  number  of  infections 
which  afford  infection  atria  for  the  ordinary  pyogenic  cocci  (diphtheria, 
scarlet  fever,  measles,  smallpox),  or  for  the  specific  micro-organisms 
of  the  disease  alone  or  combined  with  other  bacteria  (typhoid  fever, 
pneumonia,  gonorrhea,  erysipelas,  epidemic  cerebrospinnl  meningitis, 
infiuen/a). 

Not  only  sta])hyloc()eci  and  streptococci,  but  also  the  rarer  forms  of 
pyogenic  bacteria,  among  these  the  bacillus  of  pneumonia  and  the  men- 
ingococcus, are  found  in  the  different  forms  of  arthritis.  The  staphy- 
lococci and  streptococci  produce  particularly  the  severe,  but  are  also 
fonnd  in  the  mild  forms. 

Morbid  Anatomy. — When  one  comes  to  the  consideration  of  inflam- 
mation, the  synovial  membrane  is  the  most  important  ])ai't  of  the  joint. 
The  lining  of  tlic  joint  capsule,  the  stratum  synoviale,  which  differs  from 
the  str-atuni  fihrosuni  external  to  it,  extends  to  the  edges  of  the  articular 
cartilages.  The  free  surface  of  the  stratum  synoviale  is  not  covered  with 
epithelium  or  endothelium,  but   by  a  thin  layer  of  regularly  arranged, 


THE   PYOGENIC   INFECTIONS  OF   DIFFERENT  TISSUES         203 

epithelial-like  connective  tissue,  which  is  provided  with  fine,  threadlike 
or  larger  leaflike  processes,  the  synovial  villi,  some  of  which  contain  fat. 
The  synovial  membrane  and  its  villi  are  very  vascular,  and  the  capillaries 
penetrate  into  the  fine,  epithelial-like  connective  tissue. 

The  synovial  membrane  is  also  provided  with  a  well-developed  lym- 
phatic plexus,  which  is  not,  however,  in  open  connnunication  with  the 
cavity  of  the  joint,  as  the  lymphatic  plexuses  of  the  serous  mcinhi-anes 
are  with  the  serous  cavities. 

Clinical  Forms. — The  symptoms  of  inflammation  follow  infection. 
A  small  amount  of  the  exudate  is  poured  out  into  the  tissue  of  the  cap- 
sule, the  greater  amount  into  the  cavity  of  the  joint.  It  makes  no  dif- 
ference whether  the  bacteria  have  been  carried  into  the  loose  connective 
tissues  of  the  synovial  mcMubrane  by  injury,  have  reached  it  through  the 
blood,  or  whether  an  osteomyelitic  focus  has  rupturc^l  into  the  joint  and 
infected  the  entire  surface  of  the  membrane.  AVe  distinguish  according 
to  the  character  of  the  exudate  three  principal  forms  of  synovitis  (ar- 
thritis if  not  only  the  synovial  membrane,  but  all  the  tissues  of  the  joint 
are  involved),  the  serous,  fibrinous,  and  suppurative.  There  are  a  num- 
ber of  transitional  forms.  Sometimes  a  fourth  form,  the  ichorus  syno- 
vitis (in  open  wounds),  occurs  when  there  is  an  infection  with  putre- 
factive bacteria. 

Serous  and  serofibrinous  synovitis  is  a  mild  form.  It  develops 
after  open  injuries  of  the  joints,  secondary  to  encapsulated  suppurating 
foci  in  the  epiphysis,  and  to  adjacent  inflammation,  in  infectious  diseases 
(pneumonia,  typhoid  fever,  gonorrhea,  etc.),  and  especially  in  general 
infections. 

It  develops  acutely  in  one  or  more  joints.  The  joint  involved  is  pain- 
ful, tense,  and  becomes  considerably  swollen.  The  skin  covering  it  may 
be  hot  and  reddened.  The  function  of  the  joint  is  interfered  with,  there 
is  some  fever,  and  the  general  symptoms  vary. 

If  there  is  a  large  amount  of  serous  exudate,  the  joint  capsule  and 
the  bursiie  communicating  with  the  joint  become  distended  and  promi- 
nent where  anatomical  relations  permit  (in  the  knee  joint,  at  the  sides 
of  the  ligamentum  patellae  and  upper  recess).  Fluctuation  is  plainly 
made  out,  and  the  patella  is  raised  from  its  nornuil  position  and  floats. 
The  normal  contour  of  the  joint  is  lost,  and  is  replaced  by  that  of  the 
distended  joint  capsule  (vide  Tuberculous  Hydrops). 

If,  on  the  other  hand,  there  is  but  a  small  amount  of  exudate,  but  con- 
siderable infiltration  of  the  capsule  and  fibrinous  masses  are  deposited 
upon  the  synovial  membrane,  tumorlike  thickenings  may  l)e  felt,  espe- 
cially at  the  points  of  reflection  of  the  capsule,  which  often  creak  when 
palpated  or  moved.  These  thickenings,  together  with  an  u'dematous  infil- 
tration of  the  peri-  and  para-articular  tissues,  render  the  outlines  of  the 


264  WOUND   INFECTIONS   TRODUCEU   BY    BACTERIA 

joint  indistinct  (particularly  in  the  phlegmonous  form  of  gonorrheal 
arthritis ) . 

As  a  rule,  when  serous  synovitis  is  properly  treated,  the  serous  exu- 
date is  absorbed  and  the  inflammation  subsides  without  leaving  any 
articular  changes.  If  the  inflammation  recurs,  a  chronic  condition  with 
hydrarthrosis  and  growth  of  villi,  as  in  traumatic  arthritis,  may  develop. 
Then,  withoiit  any  pathological  changes  in  the  articular  cartilages  or 
bones,  the  distended  capsule  may  permit  of  abnormal  movements  (flail 
joint)  or  the  development  of  luxations  and  subluxations  (for  example, 
in  typhoid  fever,  scarlet  fever,  and  smallpox). 

If  the  tissues  of  the  capsule  become  inflamed,  they  may  shrink  and 
produce  permanent  disturbances  of  motion.  These  Mall  be  still  greater 
if  there  has  been  a  large  fibrinous  exudate  which  produces  adhesions 
(especially  in  gonorrheal  arthritis). 

The  serous  exudate,  a  yellowish  fluid  somewhat  clouded  by  pus  cor- 
puscles, contains  less  mucin,  but  more  albumin,  than  synovial  fluid. 

The  fibrinous  exudate  contains,  besides  small  or  large  amounts  of  se- 
rous exudate,  large  amounts  of  fibrin,  which  occurs  in  acute  infections  in 
the  form  of  flakes  or  membranes,  loosely  attached  to  the  recesses,  folds, 
and  villi  of  the  synovial  membrane.  In  chronic  inflammations  these 
masses  of  fibrin  become  firmly  attached  to  the  hypertrophied  synovial 
membrane  and  produce  fibrinous,  or  if  organized,  fibrous,  adhesions  of 
the  opposed  surfaces. 

Treatment  of  Serous  and  Scrofihrinous  Synovitis. — In  the  acute  cases 
immobilization  of  the  joint,  after  the  removal  by  puncture  of  the  larger 
exudates,  is  often  sufficient.  In  the  recurrent  and  chronic  forms,  aspira- 
tion combined  with  irrigation  with  from  one  to  two  per  cent  carbolic  or 
boric  acid  solution  is  to  be  recommended.  Early  massage  and  careful 
passive  motion  are  required  in  those  cases  in  which  there  is  a  tendency 
to  stifl'ness. 

Besides,  one  may  attempt  to  hasten  the  absorption  of  the  inflam- 
matory infiltration  of  the  capsule  by  an  artificially  induced  hyperemia 
(painting  with  tincture  of  iodin,  treatment  with  hot-air  apparatus.  Bier's 
passive  hypera?mia). 

Suppurative  Synovitis. — Suppurative  inflammation  of  joints  (empy- 
ema) may  be  superficial  or  deep,  and  involve  the  synovial  membrane  or 
all  the  structures  of  the  joint  (synovitis  and  arthritis  (para-arthritis) 
acuta  purulenta). 

The  supei'ficial  suppurative  joint  inflammation  (synovitis  purulenta) 
— the  catarrhal  suppurative  inflammation  of  joints  of  von  Volkmann — is 
the  mild  form.  Tlu;  inflamed,  reddened,  and  thickened  folds  of  the  syno- 
vial iiicmbi-anc  secrete  a  profuse  mucopurulent  exudate  which  often  con- 
taiiiii  iibrin  flakes.     The  iullammation  involves  only  the  inner  layers  of 


THE  PYOGENIC   INFECTIONS  OF   DIFFERENT  TISSUES         265 

the  capsule,  and  if  proper  treatment  is  instituted  early  there  may  l)e  a 
restitutio  ad  integrum.  If  it  persists  for  a  lony  time  and  is  nefrlected,  this 
form  of  synovitis  becomes  a  severe  arthritis  accompanied  by  destruction 
of  the  joint. 

It  accompanies,  more  frequently  than  the  serous  and  serofibrinous 
forms,  acute  pyogenic  infections.  This  form  of  synovitis  is  caused  most 
frequently  by  staphylococci  and  streptococci ;  less  frequently  by  pneumo- 
cocci.  Streptococci  and  pneumococci  are  found  relatively  frequently  in 
the  catarrhal  suppurative  inflammations  of  the  joints,  occurring  in  small 
children,  and  now  and  then  in  inflammations  associated  with  small  osteal 
foci  (vide  Osteomyelitis  purulenta). 

The  diagnosis  of  suppurative  synovitis  is  not  difficult.  It  has  an 
acute  febrile  onset  and  the  local  symptoms  are  marked.  The  joint  is 
swollen  and  its  outlines  are  rendered  indistinct  by  the  inflammatory 
oedema ;  there  is  loss  of  function,  and  severe  pain  is  produced  by  palpa- 
tion and  movement.  Nonsuppurative  gonorrheal  arthritis  is  the  only  form 
which  resembles  it. 

The  treatment  consists  of  early  and  wide  incision  of  the  joint  with  the 
application  of  a  loose  tampon,  later  drainage  of  the  wound  and  immo- 
bilization of  the  joint  by  splints.  In  many  cases,  especially  in  strepto- 
coccic and  pnenmococcic  inflammation,  aspiration  of  the  pus  is  sufficient. 
If  a  suppurating  osteal  focus  is  the  cause,  it  must  be  removed  and  the 
joint  opened  and  drained.  If  all  the  inflammatory  symptoms  have  sub- 
sided, careful  active  and  passive  motion  should  be  employed.  If  begun 
too  early  the  local  condition  may  be  aggravated  or  general  infection 
produced. 

Deep  suppurative  arthritis  (arthritis  purulenta)  is  not  limited  to 
the  synovial  membrane.  It  involves  the  peri-  and  para-articular  tissues, 
or  ruptures  into  the  surrounding  tissues  and  phlegmons,  and  gi-avitation 
abscesses  develop  in  the  spaces  between  muscles  and  fascia'.  Finally  this 
form  of  inflannnation  destroys  the  capsule  of  the  joint  and  the  articular 
cartilages.  The  severest  forms  are  caused  by  the  staphylococci  and 
streptococci. 

It  follows  injuries,  the  rupture  of  acute  oi-  chi-onic  osteal  foci  through 
the  articular  surfaces,  or  occurs  as  a  metastatic  inflammation  in  the 
course  of  general  pyogenic  infections. 

The  diagnosis  is  based  upon  the  ordinary  symptoms  of  arthritis  and 
the  two  following  characteristics :  Phlegmonous  inflannnation  of  the  tis- 
sues surrounding  the  joint  indicating  a  rupture  of  the  capsule :  lateral 
mobility  in  the  joint,  associated  with  crepitation  or  subluxatioti,  exten- 
sive destruction  of  the  capsule,  the  ligaments,  and  articular  cartilages. 

The  treatment  should  provide  for  the  free  discharge  of  pus  from  the 
joint  and  para-articular  abscesses.     Wide  incisions  should  be  made  into 


266  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

the  soft  tissues  and  free  drainage  established.  In  severe  cases  the  inci- 
sions used  for  resections  may  be  required.  If  the  local  and  general 
symptoms  do  not  subside  and  the  destruction  of  the  articular  cartilages 
becomes  more  extensive,  resection  of  the  joint  is  indicated.  In  this 
way  the  entire  inflammatory  focus  with  all  its  pockets  is  completely 
exposed.  Amputation  is  necessary  only  in  the  severest  cases  with  ex- 
tensive phlegmons,  secondary  involvement  of  the  bone,  and  general 
infection. 

Stiffening  of  the  joints,  deformities,  and  trophic  disturbances  are  the 
most  important  sequelae  of  the  inflammation  of  joints.  Stiffness  of  the 
joints  may  be  caused  by  cicatricial  contraction  of  the  capsule,  fibrous 
adhesions,  and  bony  union  of  the  articular  surfaces.  Interference  with 
motion,  due  to  cicatricial  contraction  of  the  capsule,  may  develop  in  the 
course  of  any  infection  which  is  accompanied  by  inflammatory  infiltra- 
tion of  the  capsule  and  peri-  and  para-articular  tissues.  In  the  fibrinous 
forms  of  inflammation,  the  fibrinous  masses  which  often  extend  along  the 
ligaments  and  into  the  joint  capsule  become  organized,  and  fibrous  adhe- 
sions develop  between  the  opposed  joint  surfaces  (anchylosis  fibrosa  in- 
tercartilaginea).  If  the  articular  cartilages  are  destroyed  by  severe 
inflammation,  there  develops  as  the  inflammation  subsides,  first  a  fibrous, 
later  a  bony  union  of  the  joint  surfaces  (anchylosis  fibrosa  interossea 
and  anchylosis  ossea  or  synostosis). 

In  the  treatment  of  arthritis  one  should  constantly  bear  in  mind  the 
possibility  of  the  development  of  anchylosis,  and  the  extremity  should 
be  immobilized  in  the  most  useful  position  (e.  g.,  in  inflammation  of  the 
wrist  and  elbow  joints  the  forearm  should  be  immobilized  in  supination 
and  slight  flexion ;  in  inflammation  of  the  knee  joint,  the  leg  should  be 
immol)i]ized  in  the  extended  position;  if  the  hip  is  involved  the  extremity 
should  be  somewhat  abducted).  Then  the  anchylosis  causes  the  least 
possible  disturbance  of  function. 

Passive  motion,  massage,  and  baths  are  employed  in  the  treatment 
of  anchylosis.  The  object  of  the  treatment,  which  is  begun  after  the 
inflammation  has  su])si(led,  is  to  ol)tain  as  free  motion  as  possible  with- 
out exciting  inflammation  or  doing  additional  harm.  Abnormal  posi- 
tions are  assumed  by  inflamed  joints  early.  The  patient  holds  the  limb 
in  the  position  which  is  most  coiiiforta])le  and  causes  the  least  pain. 
Often  these  abnormal  positions  correspond  to  those  in  which,  as  demon- 
strated by  Bonnet's  experiments,  thc^  joint  capacity  is  greatest. 

These  al)normal  positions,  which  are  called  arthrogenous  contractures, 
are  caused  in  the  beginning  by  reflex  muscular  contractions,  and  may 
be  corrected  under  anaesthesia.  Later  they  become  permanent,  and  there 
is  less  and  less  motion  as  anchylosis  develops.  The  elbow  and  wrist  joint 
become  ])ronated,  the  knee  joint  flexed,  the  hip  joint  flexetl  and  adducted 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT  TISSUES         267 

as  arthrogenous  contractures  and  anchylosis  develop.    "When  these  changes 
occur  in  the  foot  there  is  a  tendency  to  plantar  flexion. 

Not  infrequently  pathological  dislocations  occur.  These  are  due 
either  to  a  distention  and  weakening  of  the  capsule  by  the  exudate  (dis- 
tention-dislocation),  such  as  occur  most  frequently  in  the  hip  joint  in 
typhoid,  scarlet  fever,  and  smallpox,  or  to  the  destruction  of  the  joints 
and  articular  ends  of  the  bones  (destruction-dislocation)  by  severe  in- 
flammation. 


Fig.  119a. — Osteomyelitis  of  the   Femur.  Fig.  1196. — Specimen  Prepared  After 

Bony   anchylosis.     Dorsal   subluxation  of  Amputation. 

the  tibia.     (Man  eighteen  j-ears  of  age.) 

No  active  treatment  should  be  employed  so  long  as  there  is  inflam- 
mation. Extension  by  weight  and  pulley  is  indicated.  If  there  is  fibrous 
anchylosis,  the  adhesions  shoukl  be  carefully  broken  up  under  general 
anaesthesia  (von  Langenbeck's  "  Brisement  force  "),  and  the  extremity 


268  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

should  then  be  hnmobilized  in  the  corrected  position  for  two  or  three 
weeks.  Contractures  with  bony  anchylosis  require  a  cuneiform  resection 
of  the  articular  ends,  while  in  pathological  dislocations  a  complete  joint 
resection  must  be  performed. 

Atrophy  of  the  muscles  of  the  diseased  extremity,  particularly  of  the 
extensors,  develops  rapidly.  The  more  powerful  flexors  then  produce 
flexion  contractures. 

This  atrophy  is  not  due  to  the  inactivity  of  the  muscles,  but,  accord- 
ing to  the  Paget-Vulpian  theory,  is  to  be  regarded  as  a  reflex  phenomenon 
(Hoffa),  The  irritation  which  affects  the  nerves  supplying  the  joint 
is  conveyed  to  the  centers  of  the  motor  nerves  in  the  cord,  and  acting 
upon  these  centers  produces  a  simple  muscle  atrophy  (without  the  reac- 
tion of  degeneration). 

After  the  inflammation  has  subsided,  massage,  active  and  passive 
motion  should  be  employed  in  the  treatment  of  the  muscle  atrophy. 

The  h.ematogenous  joint  infections  occurring  in  the  course 
OP  GONORRHEA,  PNEUMONIA,  and  TYPHOID  FEVER  are  the  most  interesting. 

A  metastatic  synovitis  (arthritis)  may  develop  at  any  time  during 
the  course  of  a  gonorrhea,  fresh  or  old,  as  soon  as  the  diseased  urethra  is 
injured  or  irritated  or  the  bacteria  penetrate  into' the  deeper  layers  of 
its  mucous  membrane.  Pregnancy,  labor,  and  the  puerperium  favor  the 
development  of  this  metastatic  infection  in  w'oman  (so-called  articular 
rheumatism  occurring  in  pregnancy  and  the  puerperium).  The  gonor- 
rheal conjunctivitis  and  stomatitis  of  the  newborn  may  be  accompanied 
by  inflammation  of  the  joints. 

The  gonorrheal  inflanmiation  may  involve  any  joint.  The  larger 
joints  (knee,  shoulder,  hip,  elbow,  wrist)  are,  however,  most  frequently 
affected.  Sometimes  one  joint  is  affected,  sometimes  many  joints  simul- 
taneously or  in  succession    (mono-  and  poly-articular  forms). 

The  knee  joint  is  most  frequently  aft'ected  in  men,  the  wrist  joint  in 
women  (Nasse).  Severe  exertion  and  injuries  are  frequently  predis- 
posing factors. 

A  gonorrheal  infection  of  a  joint  produces  a  synovitis  which  is  ac- 
companied by  a  seropurulent,  serofibrinous,  or  seroha^morrhagic  exudate. 
More  rarely  a  pure  serous  or  purulent  exudate  is  formed.  The  infec- 
tion may  produce  an  inflannnatory  infiltration  of  the  peri-  and  para- 
articular tissues,  which  is  combined  with  a  serofibrinous  or  fibrinopuru- 
lent  exudate.  The  entire  capsule,  the  ligaments,  tendon  sheaths,  bursfE, 
and  tissues  surrounding  the  joint  then  become  involved  in  the  inflam- 
mation. The  ])lilegmonous  forms  ai-c  most  frequently  accompanied 
by  an  inllanitiialion  of  the  ])ai'a-ar1i('ular  tissues  and  pufsue  the  severest 
course. 

Pain  in  the  joint  may  be  the  only  symptom  of  the  mildest  form  of 


THE   PYOGENIC    INFECTIONS   OF   DIFFERENT   TISSUES 


269 


gonorrheal  arthritis.     The  pain  persists  for  a  long  time  without  any 
other  symptom  of  inflammation,  and  may  produce  stiffness  of  the  joint. 

According-  to  Koeuig,  there  is  apparently  in  these  cases  a  fibrinous 
inflammation  of  the  joint. 

The  inflanniiatory  exudate  in  the  joint  and  soft  tissues  frequently 
contains  gonococci,  as  was  flrst  demonstrated  by  Nasse  and  Kindfleisch 
in  a  number  of  cases.  It  is  not  difficult  to  demonstrate  gonococci  if  suit- 
able culture  medium  is  used,  and  recent  cases,  at  least  not  older  than 
one  week,  are  examined. 

Occasionally  the  ordinary  pyogenic  bacteria,  Avhich  have  entered 
through  the  diseased  mucous  membrane  or  have  been  introduced  witli 
an  aspirating  needle,  are  found  in  the  exudate.  Tliey  cause  the  phleg- 
monous forms  of  arthritis,  which  are  often  associated  with  general 
symptoms. 

(lonorrheal  arthritis  frequently  develops  acutely.  The  suddenness 
with  which  the  symptoms  develop  is  frequently  one  of  the  best  diag- 
nostic signs.  In  many  cases  wan- 
dering joint  and  muscle  pains  are 
noted  for  some  time,  and  then  the 
inflanniiation  develops  subaeutely  in 
a  number  of  joints.  The  gonorrheal 
hydrops  may  develop  very  slowly. 

The  fever  which  is  almost  al- 
ways present  in  the  beginning  be- 
comes high  in  the  severest  cases  only 
and  falls  in  a  few  days  if  the  ex- 
tremity is  innnobilized. 

Gonorrheal    arthritis    pursues    a 
chronic  course.     The  hydrops  is  the 
only  form  which  may  subside  rap- 
idly,   but    it   tends    to    recur.      The 
suppurative     and     phleg- 
monous    forms,     on     the 
other   hand,   are   very   re- 
sistant   to    treatment,    al- 
though   they    only    rarely 
result    in    abscess    forma-    / 
tion.  1^ 

After      one      or      two      i  i 
months      the      pain      and 
swelling    subside ;    in    the 
meantime  the  muscles  atroph>   and  tlie  contracture  of  tbe  joint,  which 
in  the  beginning  was  mostly  reflex,  is  folU)\ved  by  anchylosis. 


;.  120. — Bony  Anchylosis  of  the  Knek  Joint  in 
THE  Valgus  Position  Following  a  Gonorhhkal 
Arthritis. 


270  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

TLe  contraction  of  the  infiltrated  peri-  and  para- articular  tissues, 
but  still  more  the  adhesions  resulting  from  the  organization  of  the 
fibrinous  masses  in  the  joint  cavity,  produce  an  anchylosis.  In  the 
beginning  there  may  be  but  a  partial  or  extensive  fibrous  anchylosis, 
but  later  when  the  articular  cartilages  are  destroyed  a  bony  anchylosis 
develops  which  is,  as  a  rule,  never  complete,  but  there  is  no  evidence 
upon  section  or  in  Rontgen  pictures  of  any  joint  cavity  (Fig.  120). 

The  general  condition  is  less  affected  by  the  infection  than  by  the 
severe  pain. 

The  sequelse  of  gonorrheal  arthritis  are,  besides  anchylosis,  contrac- 
tures and  subluxations.  The  latter,  due  to  a  distention  of  the  capsule 
and  relaxation  of  the  ligaments,  may  occur  even  after  two  weeks  (Ben- 
necke ) . 

The  acute  onset  and  intense  pain,  which  is  aggravated  by  pressure 
and  motion,  are  important  in  making  a  diagnosis  of  the  exudative  form 
of  gonorrheal  arthritis,  and  in  differentiating  it  from  other  inflamma- 
tions. The  swelling  which  develops  in  the  phlegmonous  forms  is  not 
sharply  limited,  sometimes  it  has  a  doughy  feel  and  at  other  times  fluc- 
tuates in  certain  areas.  The  skin  covering  the  swelling  is  red  and 
oedematous.  The  fever,  as  a  rule,  is  not  high,  and  this  often  enables 
one  to  differentiate  the  phlegmonous  form  from  suppurative  arthritis 
due  to  the  ordinary  pyogenic  bacteria.  Often  a  bacteriological  examina- 
tion of  the  aspirated  fluid  is  necessary  before  a  differential  diagnosis 
can  be  made.  Fewer  joints  are  involved  in  gonorrheal  arthritis  than 
in  articular  rheumatism,  and  the  pain  is  more  intense.  An  existing  gon- 
orrhea makes  probable  the  diagnosis  of  gonorrheal  arthritis.  The  rarer 
subacute  and  chronic  forms  cannot  be  easily  differentiated  from  tuber- 
culous and  syphilitic  arthritis. 

The  phlegmonous  form  in  the  chronic  stage  may  resemble  the  tumor 
albus. 

The  prognosis  as  to  life  is  good  if  a  severe  and,  as  a  rule,  fatal  endo- 
carditis does  not  develop.  The  prognosis  as  to  function  is  best  in  the 
gonorrheal  hydrops.  The  suppurative  and  phlegmonous  forms,  accom- 
panied by  an  infiltration  of  the  soft  tissues,  are  often  followed  by  anchy- 
losis and  joint  changes. 

The  disease  may  last  from  four  weeks  to  many  months.  The  duration 
depends  upon  the  severity  of  the  infection  and  the  number  of  relapses. 
It  may  recur  in  a  joint  which  has  already  been  involved,  so  long  as  the 
gonorrhea  persists. 

vXbsohite  rest  of  th(>  joint,  which  should  be  maintained  as  long  as 
fever,  ]);iiii,  and  swelling  persist,  is  the  most  important  part  of  the  treat- 
ment. Ill  most  cases  the  inflammation  will  subside  and  contractures  bo 
prevented.     Immobilizing  dressings  should  be  used  for  this  purpose;  in 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT  TISSUES  271 

inflainniation  of  the  hip  these  may  be  eombiiied  with  extension.  If  the 
exudate  is  large,  aspiration  with  subsequent  compression  may  be  neces- 
sary. The  injection  of  five  per  cent  carbolic  acid  (up  to  8  c.c.)  has  been 
iised  by  Koenig.  Incisions  should  be  made  only  when  abscesses  develop 
and  in  the  phlegmonous  forms  (particularly  in  mixed  and  secondary 
infections). 

If  anchylosis  develops,  active  and  passive  motion  should  be  employed 
and  the  immobilizing  dressing  removed.  The  latter  should  be  applied 
again  if  fever  follows  use  of  the  joint.  In  bad  cases  an  am^sthetic 
should  be  given  when  the  adhesions  are  broken  up  and  the  contractures 
corrected.  This  procedure,  which  is  often  successful,  is  exceedingly 
painful,  and  cannot  be  satisfactorily  performed  unless  an  ana?sthetic  is 
administered. 

Bier's  passive  hyperemia  has  a  favorable  influence  in  many  cases. 
It  controls  the  pain  and  permits  of  early  movement.  The  toxins  are 
diluted  by  the  increased  transudate  and  are  gradually  absorbed. 

In  the  loAver  extremity  a  resection  of  the  joint  may  be  required  to 
correct  the  malposition.  In  the  upper  extremity  (shoulder  and  elbow 
joints)  soft  tissues  should  be  placed  between  the  resected  parts  of  the 
lione  in  order  to  obtain  movement. 

In  rare  cases  during  the  course  of  a  croupous  pneumonia  one  or 
many  joints  may  become  involved.  This  arthritis,  which  develops  most 
frequently  wdien  the  disease  is  at  its  height,  is  caused  by  the  pneumo- 
coccus.  The  serofibrinous  or  suppurative  catarrhal  synovitis  (arthritis) 
pursues  an  acute  course,  and  if  there  are  symptoms  which  indicate  gen- 
eral infection,  endocarditis,  or  suppuration  in  the  serous  cavities,  the 
prognosis  is  bad.  In  favorable  cases  the  synovitis  subsides  after  immo- 
bilization, combined  with  puncture  and  aspiration  if  the  exudate  is 
serous,  with  incision  if  purulent.  As  a  rule,  there  is  restitutio  ad  inte- 
grum. Pneumococcic  arthritis  without  a  preceding  pneumonia  is  rare 
in  adults.  It  is  more  fre(iuent  in  small  children,  developing  secondarily 
to  foci  in  the  articular  ends  of  bone  {vide  Osteomyelitis).  Ap]iar('ii1ly 
an  inflamed  pharyngeal  mucous  membrane  afifords  the  infection  atrium. 

S.ynovitis  occurring  during  the  course  of  typhoid  fever,  and  caused 
by  the  typhoid  bacilli,  is  rare.  This  form  of  arthritis  develops  during 
convalescence  and  pursues  a  benign  course.  The  inflannnation  subsides 
after  aspiration  of  the  serous  or  serohemorrhagic  exudate  and  immobili- 
zation, if  there  is  no  mixed  infection  with  staphylococci  or  streptococci 
which  produce  severe  and  destructive  forms  of  suppuration. 

Literature. — Bennecke.  Die  gonorrhoische  Gelenkontziindunia:.  Berfin,  1899. — 
Cave.  Pneumococcic  arthritis.  The  Lancet,  1901. — Hartmann.  XTeber  die  Behand- 
lung  der  akuten  primar  synovialen  Eiterungen  der  grossen  Gelenke.  Deutsche  Zeitschr. 
f.  Chir.,  Bd.  57,   1900,  p.  231.— Heile.     Ueber  d.  Zerstorung  d.  hyalinen  Gclenkuud 


272  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

Epiphysenknorpels  bei  Tuberkulose  unci  Eiterung.  Virchows  Arch.,  Bd.  103,  1001,  p. 
265. — Hoffa.  Die  Pathogenese  der  arthritischen  Muskelatrophien.  Chir.-Kongr. 
Verhandl.,  1892,  I,  p.  93. — Kunig.  Ueber  gonorrhoische  Gelenkentziindungen. 
Deutsche  med.  Wochenschr.,  1896,  p.  751. — Mauclaire.  Des  Arthrites  suppurees. 
Paris,  1895. — Nasse.  Die  gonorrh.  Entziindungen  der  Gelenke  u.  s.  w.  v.  Volkmanns 
Samml.  klin.  Vortr.,  N.  F.,  181,  1897. — Pfisterer.  Ueber  Pneuniokokkengelenk-  und 
Knocheneiterungen.  I.-D.  Berhn,  1902. — Predtetschensky.  Akuter  und  chronischer 
Gelenkrheuniatismus.  Zentralbl.  f.  Grenzgeb.,  Bd.  5,  1902,  p.  657. — Schuchardt. 
Die  Krankheiten  der  Knochen  und  Gelenke.  Stuttgart,  1899. — Witzel.  Die  Gelenk- 
und  Knochenerkrankungen  bei  akuten  infektiosen  Erkrankungen.     Bonn,   1890. 

(g)     PYOGENIC   DISEASES  OF    TENDON    SHEATHS  AND   BURSiE 

Etiology. — Inflammation  of  tendon  sheaths  and  bursne  follows  most 
frequently  oj)en  injuries,  penetrating  foreign  bodies,  and  the  extension 
of  inflammation  from  neighboring  foci  (suppurating  wound  of  the  skin, 
furuncle,  subcutaneous  phlegmon,  erysipelas,  etc.).  Hematogenous  in- 
fections are  more  rare.  Staphylococci  and  streptococci  are  found  most 
frequently  in  these  inflammations;  the  latter  especially  in  the  severe 
forms.  Other  bacteria,  such  as  the  gonococcus,  pneumococcus,  bacterium 
coli  commune,  etc.,  are  found  but  rarely. 

Pathology. — These  inflammations  have  an  acute  onset,  associated  with 
fever.  In  the  beginning  the  exudate  is  serous,  but  it  rapidly  becomes 
purulent.  The  extension  of  the  inflammation  depends  upon  the  ana- 
tomical relations  and  the  size  of  the  tendon  sheaths  and  bursae,  and  for 
this  reason  the  clinical  picture  is  often  very  characteristic.  If  the  in- 
flammation is  limited  to  the  wall  of  the  tendon  sheath  or  bursa,  it  becomes 
covered  with  granulation  tissue  (pyogenic  membrane).  If  a  severe  in- 
flammation produces  after  a  few  days  a  necrosis  of  the  sheath  or  bursa, 
the  inflammation  extends  rapidly  and  widely  into  the  intermuscular  and 
subcutaneous  tissues.  Then  the  clinical  picture  changes  to  that  of  a  cir- 
cumscribed or  progressive  phlegmon.  In  the  former  the  pus  gradually 
ruptures  through  the  skin,  and  fistulre  are  found  which  are  resistant 
to  treatment,  while  in  the  latter  the  inflammation  extends  far  beyond 
the  sheaths,  the  walls  of  which,  as  well  as  the  tendons  and  their  accessory 
bands,  become  necrotic. 

The  tendon  is  affected  early  by  the  inflammation  which  extends  along 
the  synovial  membrane,  covering  the  tendon  and  lining  the  sheath.  The 
connective  tissue  septa  become  filled  with  leucocytes  in  the  first  few  days, 
and  karyokinetic  figures  and  an  increase  of  the  cells  in  the  tendon  indi- 
cate a  reactive  growth.  Necrosis  of  the  tendon  begins  in  from  three  to 
five  days.  It  becomes  fibrillated  and  necrotic.  If  such  a  tendon  is  not 
removed  it  acts  as  a  foreign  body,  lik(>  a  sequestrum  in  bone,  and  a 
chronic  suppurating  fistula  develops.  A  little  of  the  tendon  may  sur- 
vive and  become  united  with  the  cicatricial  tissue,  which  develops  from 


THE  PYOGENIC   INFECTIONS  OF   DIFFERENT  TISSUES         273 

the  granulations  after  the  necrotic  tendon  has  been  extruded.  This 
cicatricial  tissue  interferes  with  the  function  of  the  part  involved. 

Inflammation  op  a  bursa  (bursitis  acuta  purulciita)  is  character- 
ized clinically  by  a  rapidly  developing,  painful,  circumscribed,  fluc- 
tuating swelling,  which  develops  in  the  position  of  a  nuicous  bursa  (e.  g., 
bursa  pra^patellaris,  olecrani). 

Tlie  skin  covering  the  bursa  becomes  oedematous  and  r(Mldened.  The 
l)orders  of  the  redness  are  not  sharply  defined.  The  i>us  cither  ruptures 
tlu'ough  the  skin,  producing  a  chronic  fistula,  or  extends  beneath  the 
fascia  covering  the  bursa  and  produces  a  large  phlegmon.  If  the  bur- 
sitis develops  from  a  wound  in  the  skin  covering  the  bursa,  lymphangitis 
and  erysipelas  often  develop  sinuiltaneously. 

Inflammation  of  a  tendon  sheath  (tendovaginitis  acuta  puru- 
leuta)  (phlegmon  of  the  tendon  sheath,  panaritium  tendinosum)  begins 
with  a  swelling  which  extends  rapidly  along  the  tendon  sheath  and  is 
associated  with  loss  of  function  of  the  part  involved,  pain  ui)on  ])ressure, 
an*l  motion  and  some  reddening  of  the  skin.  Fluctuation  is  first  elicited, 
when  there  is  a  large  collection  of  pus,  particularly  after  the  process  is 
encapsulated,  and  shortly  before  it  ruptures  through  the  skin. 

The  dangers  and  results  of  a  suppurative  bursitis  lie  in  the  exten- 
sion of  the  infiammatiou  to  a  neighboring  jcint.     Those  of  a  synovitis. 


Fig.  121. — Cicatricial,  Contracture  of  the  Thumb  Following  a  Suppurative  Inflamma- 
tion OF  THE  Synovial  Sheaths  op  the  Flexor  Tendons  of  the  Thumh  and  Little 
Finger,  the  So-called  V-Phlegmon.  The  inflammation  followocl  a  punctured  wound 
of  the  little  finger  which  was  disarticulated  because  of  osteomj^elitis. 

leaving  out  of  consideration  a  progressive  phlegmon,  lie  in  the  disturb- 
ance of  function  produced  by  the  destruction  of  the  tendons  and  the 
contractures  following  the  contraction  of  the  cicatricial  masses.  A  gen- 
eral pyogenic  infection  may  follow  a  phlegmon  which  develops  after 
rupture  of  the  synovial  sheath.  The  diagnosis  is  not  difficult.  The  posi- 
tion of  the  acute  inflammatory  swelling  indicates  with  certainty  that 
cither  a  bursa  or  a  tendon  sheath  is  involved.  In  the  latter  the  inflam- 
mation extends  along  definite  anatomical  routes.  An  infiammatiou  of 
the  sheaths  of  the  flexor  tendims  of  the  scc(md,  third,  and  fourth  fingers 
extends  only  to  the  transverse  furrow  of  the  palm,  as  the  sheaths  end 


274  WOUND    INFECTIONS   PRODUCED   BY    BACTERIA 

here.  Inflammation  of  the  sheaths  of  the  thumb  and  little  finger  extends 
to  the  wrist  joint  or  even  higher,  for  frequently  the  sheaths  of  these 
fingers  communicate  with  the  sheath  which  is  common  to  the  superficial 
and  deep  flexors. 

The  treatment  of  acute  suppurative  hiirsitis  (bursitis  acuta  puru- 
lenta)  consists  of  incision  and  the  after-treatment  which  is  employed  in 
suppurative  inflanniiation.  In  the  treatment  of  tendovaginitis  it  should 
be  especially  kept  in  mind  that  the  earlier  the  incision  is  made  and  the 
pus  is  allowed  to  escape  the  better  will  be  the  prognosis,  both  as  regards 
the  repair  of  the  tendon  and  the  later  restoration  of  function,  as  early 
incision  prevents  the  formation  of  broad  adhesions  between  the  tendon 
and  its  sheath. 

The  incision  should  be  made  so  that  there  will  be  the  least  possible 
cicatricial  contraction.  This  always  follows  incisions  made  directly  over 
the  tendon  Avhich  extend  thr(nigh  the  synovial  sheath  and  its  transverse 
connective  tissue  bundles.  It  may  be  avoided  if  small  incisions  are  made. 
The  incisions  should  be  made  at  the  side  of  the  tendon,  and  the  transverse 
fibers  of  the  sheath  and  the  corresponding  skin  (transverse  furrows  in 
the  fingers,  in  the  wrist  especially  the  lig.  carpi  volare)  should  be  avoided. 

These  small  incisions  frequently  control  the  inflammation  and  permit 
of  a  complete  restoration  of  function.  AVhen  they  do  not  provide  for  a 
free  discharge  of  pus  and  control  the  phlegmon  an  incision  must  be 
made  through  the  folds  of  the  skin,  the  tendon  sheaths,  and  the  support- 
ing ligaments  of  the  joints.  Then  the  fate  of  the  tendon,  associated  with 
complete  loss  of  function,  is  sealed. 

If  the  inflammation  is  mild  from  the  beginning,  the  extremity  may  be 
immobilized,  elevated,  and  treated  expectantly.  Sometimes  in  staphy- 
lococcic and  gonorrheal  infections  the  inflammation  subsides  or  an  ab- 
scess forms. 

Little  is  to  be  expected  as  regards  restoration  of  function  in  the  treat- 
ment of  cicatricial  contractures  following  phlegmonous  tendovaginitis. 
The  mechanical  treatment,  stretching  of  the  scar,  is  naturally  not  suc- 
cessful, because  of  the  anchylosis,  the  result  of  the  accompanying  ar- 
thritis. This  treatment  is  rarely  successful,  even  when  the  joints  are  not 
involved. 

An  excessive  stretching  of  the  scar  may  be  followed  by  an  increased 
contraction.  The  finger  may  be  straightened  by  excising  the  scar  and 
skin  grafting  the  defect,  but  there  will  be  no  return  of  motion.  It  is 
rare  to  obtain  even  a  little  motion,  for  when  the  scar  is  carefully  dissected 
away  from  the  tendon,  new  adhc^sions  develop. 

Amputation  is  indicated  if  the  life  of  the  patient  is  threatened  by 
general  pyogenic  infection  or  if  the  deformity,  resulting  from  cicatricial 
contraction,  interferes  with  work. 


THE   PYOGENIC    INFECTIONS   OF   DIFFERENT  TISSUES         275 

Acute  gonorrheal  bursitis  and  tendovaginitis  should  be  especially 
iiieiitioiied.  Frequently  a  serous,  more  rarely  a  suppurative  bursitis  or 
tendovaginitis  is  associated  with  a  gonorrheal  arthritis.  They  are,  as  a 
rule,  benign ;  and  subside  spontaneously.  Adhesions  rarely  form  between 
the  tendon  and  the  sheath,  and  there  is  no  disturbance  of  function. 

The  bursa  of  the  tendo  Aehillis,  the  sheaths  of  the  flexor  and  extensor 
tendons  of  the  fingers,  and  the  sheaths  of  the  tendons  passing  behind  the 
internal  malleolus  are  most  frequently  involved   (Nasse). 

The  extremity  should  be  innnobilized  as  long  as  the  symptoms  of 
inflammation  persist.  Large  serous  exudate  should  be  aspirated,  large 
purulent  exudates  incised,  and  active  and  passive  motion  should  be  be- 
gun at  the  proper  time.  Rapid  healing  and  good  function  are  obtained 
when  proper  treatment  is  instituted.  Chronic  changes  w^ith  adhesions 
may  follow  this  type  of  inflammation  (Nasse), 

Literature. — v.  Bergmann.  Die  Behandlung  der  akut  progred.  Phlegmone. 
Arbeiten  aus  der  v.  Bergniannschen  Klinik,  Bd.  15,  1901. — Jukobi  und  Goldmann. 
Tendovaginitis  supi)urativa  gonorrhoica.  Beitr.  zur  klin.  Chir.,  Bd.  12,  1894,  p.  827. — 
Ndsse.  Die  gonorrh.  Entziindiuagen  der  Gelenke,  Sehnenscheiden  und  Sclileinibeutel. 
V.  Volkmanns  Samml.  klin.  Vortr.,  N.  F.,  181,  1897. 


(h)     THE   PYOGENIC    DISEASES   OF   MUSCLES   AND   THE 
SUBFASCIAL   AND   INTERMUSCULAR   PHLEGMON 

Acute  Suppurative  Myositis  (Myositis  Acuta  Punih  nta). — Acute  sup- 
purative myositis,  like  every  pyogenic  infection,  may  develop  in  different 
ways.  The  interstitial  tissue,  as  well  as  the  contractile  substance  of  the 
nuisele,  may  be  involved.  We  speak  of  an  interstitial,  which  is  as  a  rule 
suppurative,  more  rarely  serous  or  serofibrinous,  and  of  parenchymatous- 
degenerative  myositis. 

Ectogenous  infections  follow  most  frequently  wounds  in  which  nuis- 
cles  have  been  crushed  or  lacerated  (compound  fractures,  gunshot  frac- 
tures with  laceration  and  contusion  of  muscles,  bites  by  animals  suffer- 
ing from  hydrophobia,  machine  injuries,  etc.). 

Llixed  infections  with  a  number  of  pyogenic  bacteria,  also  combined 
with  putrefactive  bacteria,  are  most  frecpient.  If  the  cutaneous  wound 
is  small  and  its  edges  become  cpiickly  agglutinated,  as  in  gunshot  and 
stab  wounds,  and  in  fractures  in  which  a  sharp  fragment  pierces  the  skin, 
an  inflaunnation  of  the  injured  muscle  may  not  develop  unless  bacteria 
are  carried  into  the  wound  by  improper  treatment,  irrigation,  and  prob- 
ing of  the  wound. 

Inflammation,  which  is  as  a  rule  suppurative,  may  extend  from  adja- 
cent foci.  A  phlegmonous  erysipelas,  a  sul)cutaneous  plilegmon,  tendo- 
vaginitis, lymphangitis,  lymphadenitis,  ])hU'bitis,  osteomyelitis,  etc.,  nuiy 


276  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

extend  to  the  loose  intermuscular  connective  tissues.  After  the  fascia 
is  destroyed  the  inflammation  attacks  the  perimysium  and  the  interstitial 
tissue.  These  are  destroyed  by  suppuration,  and  the  contractile  substance 
of  the  muscle  becomes  necrotic. 

A  ha^matogenous  infection  occurring  in  the  course  of  a  general  pyo- 
genic infection  may  produce  a  circumscribed  suppiirative  inrtaiiuuation 
in  one  cr  many  muscles.  The  muscles  may  be  attacked  simultaneoush^ 
or  in  succession.  This  form  of  myositis  is  most  fre([uently  caused  by 
staphylococci  and  streptococci,  more  rarely  by  the  pneumococcus  and 
gonococcus,  colon  and  t.yphoid  ])acilli  (following  typhoid  fever),  and  in- 
fluenza bacilli.  A  subcutaneous  muscle  injury  (laceration,  contusion  with 
hajmatoma)  may  suppurate  if  there  is  inflammatory  focus  (felon,  angina) 
from  which  the  bacteria,  which  later  are  deposited  in  the  injured  tissue 
(locus  nnnoris  resistentite),  may  be  absorbed. 

A  beginning  myositis  is  indicated  by  a  painful  swelling  of  the  muscle, 
complete  loss  of  function,  and  fever.  The  muscle  involved  becomes  en- 
larged and  hard,  and  its  boundaries  cannot  be  accurately  determined  be- 
cause of  the  (edema  of  the  surrounding  structures,  the  subcutaneous 
tissue  and  skin.  AVhen  the  hard  infiltrated  area  softens  we  have  the 
symptoms  of  an  abscess,  which  later  ruptures  through  the  skin. 

A  progressive  inflannnation  produces,  after  extending  to  the  inter- 
stitial tissue,  a  destruction  of  the  entire  muscle,  and  then  extends  to 
the  surrounding  tissues.  Permanent  loss  of  function  and  contractures 
follow  if  a  fatal  general  infection  does  not  develop.  The  severest  forms 
of  interstitial  myositis  are  followed  by  large  defects  in  the  muscle  which 
are  replaced  by  scar  tissue. 

A  circumscribed  abscess  develops  if  the  interstitial  pyogenic  mem- 
brane encapsulates  the  pus,  resulting  from  a  destruction  of  the  inflamed 
tissues.  After  the  pus  is  evacuated  by  incision  or  discharged  spontane- 
ously, scar  tissue  fills  in  the  defect.  This  scar  tissue  does  not  inter- 
fere with  the  function  of  the  muscle  unless  the  abscess  has  been  very 
large. 

Secondary  myositis,  developing  from  an  adjacent  suppurative  osteo- 
myelitis or  lymphadenitis,  frequently  pursues  a  mild  course  with  only  a 
serous  exudate,  and  subsides  si)ontaneously.  The  formation  of  scar  tissue 
and  degeneration  of  the  contractile  substance  (myositis  fibrosa),  which 
interfere  with  the  function  of  the  muscle,  are  the  usual  results. 

In  making  a  diagnosis  it  is  important  to  note  that  the  hard,  painful 
swelling  which  develops  suddenly  and  gradually  softens,  corresponds 
to  the  position  of  the  muscle,  and  that  the  inflannnation  extends  within 
the  limits  of  the  muscle.  If  the  (edema  of  the  surrounding  tissues  is 
marked,  the  development  of  a  swelling  which  extends  down  to  the  bone 
is  suggestive  of  myositis.    A  myositis  may  be  mistaken  most  easily  for  an 


THE   PYOGENIC   INFECTIONS   OF   DIFFERENT  TISSUES         277 

inflaniiiiatory  sw(>]]iiis  associated  Avitli  an  inflaininatioii  of  the  dcvp  lym- 
phatics or  a  suppurative  osteoiuyelitis. 

The  treatment  consists  of  large  incisions  which  sliouUl  he  made  par- 
allel to  the  muscle  fihers.  The  after-treatment  is  cari-ied  out  accordin.u'  to 
rules  already  given  {vide  p.  199),  disturhances  of  function  due  to  scar 
tissue  may  be  overcome  by  operative  nu^asures.  The  distal  tendon  of  the 
degenerated  muscle  may  be  cut  transversely  and  united  with  the  border 
of  a  healthy  nniscle,  or  with  a  pedunculated  muscle  (lap  ta]<en  from  an 
adjacent  muscle. 

Literature. — -Ileinrich  Lorenz.  Die  Muskelerkninkvmgeii.  In  Nothnagels  spez. 
Pathologie  unci  Therapie,  Bel.  11,  Wien,  1898. 

Subfascial  and  intermuscular  phlegmons,  each  of  which  may  develop 
from  the  other,  follow  subcutaneous  phlegmons,  the  rupture  of  suppu- 
I'ative  inflammation  of  tendons,  muscles,  joints,  bones,  and  infection  of 
the  connective  tissue  surrounding  the  oesophagus.  These  phlegmons  also 
develop  in  deep  wounds  and  in  the  course  of  ]netastatic  infections. 

They  spread  in  the  loose  connective  tissue,  filling  the  intermuscular 
spaces,  particularly  along  the  connective  tissue  surrounding  the  large 
vessels  (e.  g.,  vascular  sheath  in  the  neck,  axillary  and  popliteal  fossa')- 

The  brawny  induration  of  the  soft  tissues,  the  reddening  and  oedema 
of  the  overlying  skin,  fever,  pain,  and  loss  of  function  are  the  most 
important  symptoms.  In  favorable  cases  the  indurated  area  softens  and 
the  pus  is  discharged.  Frequently,  however,  dangerous  complications 
follow  the  rapid  extension  of  the  inflanunation.  A  phlegmon  of  the  neck 
may  extend  to  the  mediastinum  or  cause  a  fatal  oedema  of  the  glottis. 

Large  incisions  should  be  made  early.  The  tissues  surrounding  the 
large  vessels  and  filling  the  intermuscular  spaces  must  be  exposed.  If 
an  original  focus  (e.  g.,  perforation  of  the  o'sophagus,  sup])urative  o.steo- 
myelitis  or  arthritis)  exists,  it  should  be  found  when  possible.  In 
the  after-treatment,  care  sh(mld  be  exercised  to  prevent  llie  ei-osion 
of  large  vessels.  Drainage  tubes  should  be  carefully  placed ;  hard,  re- 
sistant tubes  should  not  be  used  {vide  Arteritis). 

Literature. — E.  v.  Bergmann.  Die  Behandhing  der  akut  progredionfen  Phlcgnione 
V.  Bergmannsche  Arbeiten,  Bd.  15,  1901.     Berlin,  Hirschwald. 

Woody  phlegmon  (brawny  induration)  of  Reclus  is  a  peculiar  in- 
flammation, which  involves  most  frequently  the  intermuscular  and  sub- 
cutaneous tissues  of  the  neck.  It  pursues  a  chronic  course,  with  little 
fever,  a  boardlike  hardness,  and  almost  painless  swelling  of  the  soft 
tissues. 

There  is  but  little  tendency  to  suppuration. 

Streptococci,  staphylococci,  pneumococci,  and  diphtheria  bacilli  have 
been  found  in  the  exudate,  which  is  small  in  amount.  Sometimes  bac- 
19 


278  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

teria  are  looked  for  in  vain.  These  inflammations  develop  most  often 
from  the  mucous  membrane  of  the  floor  of  the  mouth  and  pharynx. 
Apparently  they  are  caused  by  attenuated  forms  of  bacteria,  and  for  this 
reason  the  tissues  do  not  become  necrotic  and  pus  is  not  formed,  or  only 
in  small  amounts. 

If  an  incision  is  made  early,  because  of  the  dano;er  of  (edema  of  the 
glottis  or  dysphagia,  the  surgeon  finds  a  brawny  indurated  connective 
tissue,  and  often  in  the  intermuscular  spaces  a  cloudy,  many  times  a 
purulent  exudate,  especially  in  the  submaxillary  region  adjacent  to  swol- 
len and  softened  lymph  nodes.  This  form  of  inflammation  may  be  mis- 
taken for  actinomycosis,  as  the  boardlike  infiltration  is  the  most  impor- 
tant characteristic  of  the  latter. 

Warm,  moist  compresses  are  to  be  recommended  to  soften  the  infil- 
trated area.  Quicker  results  are  obtained  by  incision  and  exposure  of 
the  infiltrated  intermuscular  spaces.  Even  if  pus  is  not  found  the  bac- 
teria are  removed  with  the  wound  secretion. 

Literature. — Jansson.  Holzphlegmone.  Hygieia,  Janviary  2,  1904. — Kusnetzoff. 
Ueber  die  Holzphlegmonen  des  Halses  (Reclus).     Arch.  f.  klin.  Chir.,  Bd.  5S,  1899,  p.  455. 

(i)     PYOGENIC   INFECTIONS   OF   SEROUS   CAVITIES  AND 
DIFFERENT   ORGANS 

Infection  of  the  serous  cavities  and  viscera  may  occur  from  without 
(ectogenous)  or  from  within  (endogenous).  Ectogenous  infections  fol- 
low penetrating  or  perforating  wounds  (deep  cuts,  stab  and  gunshot 
wounds)  ;  endogenous  infections  follow  traumatic  or  inflammatory  per- 
foration of  organs  lined  with  nnicous  membrane  (e.  g.,  peritonitis  follow- 
ing subcutaneous  rupture  of  the  intestine,  pleuritis  following  traumatic 
rupture  of  a  bronchiole  in  subcutaneous  fracture  of  the  ribs,  meningitis 
after  injury  of  the  internal  ear,  or  ethmoid  cells  in  fracture  of  the  base 
of  the  skull,  etc.). 

Such  an  infection  may  occur  through  the  lymphatics  (lymphogenous) 
or  by  direct  extension  (e.  g.,  pleui'isy  secondary  to  lung  abscess,  pneu- 
monia, osteomyelitis  of  a  rib,  ])eritonitis ;  meningitis  secondary  to  osteo- 
myelitis of  the  cranial  bones,  thrombo^^hlebitis  of  the  sinuses,  brain 
abscess;  peritonitis  secondary  to  pleuritis,  the  inflammation  extending 
ak^ig  the  lymphatics  of  the  diaphragm,  phlegmon  of  the  stomach,  intes- 
tines, and  abdominal  wnll ;  brain  abscess  secondary  to  extradural  suj>])n- 
ration  or  thrombophlebitis  of  the  veins  of  the  diploe;  abscess  of  the  kid- 
ii<'y  (pyonephrosis)  secondary  to  cystitis). 

ITaMiiatogenous  infection  may  involve  the  viscera  and  serous  cavities. 
In  genera]  pyogenic  infections,  accompanied  by  metastatic  inflannna- 
tions,  they  become  infected  at  the  same  time  that  other  tissues  do.     In- 


GENERAL  PYOGENIC   INFECTIONS  279 

feeted  emboli  lodge  in  the  lung  and  cause  lung  abscess ;  infection  of  the 
liver  occurs  through  the  portal  vein. 

Three  principal  forms  of  inflammation,  which  may  be  accompanied 
by  different  exudates,  are  to  be  differentiated  in  serous  cavities:  the 
circumscribed,  the  acute  progressive,  and  general  in/lammation.  In  the 
circumscribed  form  the  serous  surfaces  become  adlierent  at  the  borders  of 
the  granulation  tissue.  In  the  acute  progressive  form  the  intlaiiini.-it  ion  is 
not  encapsulated,  or  only  incompletely.  An  encai)sulated  focus  may  also 
rupture  through  the  protecting  granulation  tissue;  then  an  acute  pro- 
gressive inflammation  develops.  The  general  form  in  which  the  entire 
surface  of  serous  membranes  is  involved  develops  from  the  acute  pro- 
gressive forms. 

Following  pyogenic  infections  of  the  viscera,  circumscribed  foci, 
which  are  usually  nuiltiple,  may  develop,  or  the  inflammation  may  be 
diffuse  involving  the  entire  viscus. 

The  clinical  course,  diagnoses  and  treatment  of  these  infections  be- 
long to  the  province  of  special  surgery. 

When  suppuration  occurs  in  serous  membranes  a  wide  incision  should 
be  made,  and  free  drainage  established  as  soon  as  possible.  In  the  skull 
and  thorax  the  necessary  preliminary  operation  must  be  performed 
(trephining,  resection  of  rib).  In  the  milder  forms  of  inflammation 
puncture  with  aspiration  may  be  sutflcient  (e.  g.,  in  pleurisy,  lumbar 
puncture  in  meningitis).  AVhen  abscesses  develop  in  the  different  viscera 
they  should  be  incised;  when  possible,  and  the  conditions  found  indi- 
cate such  a  procedure,  the  entire  viscus  should  be  extirpated  (e.  g.,  kid- 
ney, testicle,  ovary,  spleen). 

Literature. — Haegler.  Ueber  das  freie  serose  Exsudat  des  Peritoneum  als  Friih- 
syinptoin  einer  Perforationsperitonitis.  Zentralbl.  f.  Chir.,  1904,  p.  282. — Xoetzel. 
Die  Prinzipien  der  Peritonitisbehandliing.  Beitrage  z.  klin.  Chir.,  Bd.  46,  1905,  p.  514; 
— Die  Behandlung  der  appendizitischen  Abszesse.  Ibid.,  Bil.  47,  1905,  p.  826. — Peiser. 
Zur  Pathologie  der  bakteriellen  Peritonitis.     Ibid.,  Bd.  45,  1905,  j).  111. 


CHAPTER    V 

GENERAL  PYOGENIC  INFECTIONS 

During  the  course  of  any  local  pyogenic  infection  micro-organisms 
and  their  toxins  may  be  absorbed,  and  groups  of  bacteria  may  invade  the 
lymphatic  vessels  and  blood  vessels  and  gain  access  to  the  blood.  A 
general  reaction  follows  the  absorption  of  infectious  materials,  which 


280  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

varies  in  intensity,  depending  upon  the  nnmber  and  virnlence  of  the  bac- 
teria absorbed  and  the  character  of  their  toxins.  This  general  reaction 
is  characterized  by  fever  and  the  symptoms  which  accompany  it. 

The  general  reaction  following  a  local  infection  is  due  to  the  absorp- 
tion of  toxins,  and  is  apparently  of  a  protective  nature.  Bacteria  are 
found  in  the  blood  quite  frequently  even  in  the  mild  general  reactions, 
but  the  latter  are  very  different  from  general  pyogenic  infections.  In 
the  general  reaction  following  a  local  infection  the  bactericidal  prop- 
erties of  the  blood  and  tissue  fluids  destroy  the  bacteria  and  neutralize 
the  toxins,  Avhile  in  the  general  pyogenic  infections  the  resistance  of  the 
organism  is  so  reduced,  or  the  bacteria  are  absorbed  in  such  large  num- 
bers and  are  so  virulent,  that  they  multiply  rapidly  and  may  be  deposited 
in  the  different  tissues  and  viscera  producing  metastatic  foci.  If  the 
bacteria  and  their  toxins  prevail  over  the  bactericidal  properties  of  the 
blood  and  tissue  fluids,  a  general  pyogenic  infection  develops. 

There  are  two  principal  forms  of  general  pyogenic  infections,  between 
Avhich  there  are  many  transitions.  The  chief  characteristic  of  one  form 
is  the  development  of  nuiltiple  suppurating  metastatic  foci,  of  the  other 
the  multiplication  of  bacteria  in  the  blood  without  the  development  of 
metastatic  foci.    I  therefore  differentiate  : 

A  general  pyogenic  infection  with  metastases  in  which  there  occur 
intermittent  transitory  infections  of  the  hlood  (metastatic  infection)  and 

A  general  jiyogenic  infection  without  metastases  in  which  there  is  a 
persistent  {toxic  and  bacterial)  infection  of  the  hlood. 

In  the  general  infection  characterized  by  metastases  the  infection  is 
spread  by  way  of  the  blood  stream  only,  and  foci  of  infection  develop 
in  different  parts  of  the  body.  The  infection  may  be  produced  in  two 
Avays:  Either  groups  of  bacteria  (bacterial  emboli)  pass  through  the 
walls  of  the  diseased  vessels  in  the  primary  focus  into  the  blood  stream, 
or  are  carried  by  pieces  of  thrombi  (infected  emboli)  which  have  been 
destroyed  by  suppuration  into  the  circulation,  producing  where  they  are 
deposited  metastatic  foci  of  suppuration.  Infarction  frequently  precedes 
the  development  of  these  foci. 

In  some  cases  the  bacteria  and  their  toxins  are  not  found  constantly 
in  the  blood,  occurring  only  when  the  bactericidal  substances  of  the 
latter  have  been  exhausted.  This  may  happen  daily  or  after  long  inter- 
vals, recurring  regularly  or  irregularly.  When  the  bactericidal  sub- 
stances are  formed  again  the  bacteria  are  removed  from  the  blood  and 
deposited  in  large  numbers  in  different  parts  of  the  body  (bone  marrow 
in  eliildrcii,  joints,  and  hu'ge  viscera)  where  they  incite  processes  which 
combat  Ihc   inrcction. 

Etiologically  v\^^v\  hiinialogcHOHs  infection  (hivmatogenous  osteomye- 
litis, arthritis,  etc.)  must  be  regarded  as  a  mild  form  of  general  pyogenic 


GENERAL   PYOGENIC   INFECTIONS  2.S1 

infection  with  ntctastascs,  roiiardlcss  of  whctlici-  or  not  a  primary  infec- 
tion atrium  can  be  found.  Clinically  a  single  metastasis  occui-rinj;  in 
the  cases  above  cited  can  only  be  regarded  as  part  of  a  general  infection, 
when  the  blood  infection  persists  and  there  are  other  symptoms  indica- 
tive of  a  g'eneral  infection. 

The  form  without  metastases  is  a  persistent  general  infection  with 
bacteria  and  their  toxins.  Theoretically  a  general  bacterial  infection 
(bacterijpmia)  may  be  differentiated  from  a  general  toxic  infection 
(toxaemia),  depending  upon  whether  the  bacteria  or  their  toxins  pre- 
dominate in  the  blood.  Such  a  distinction  cannot,  however,  be  made 
clinically. 

In  general  hacterial  infections  the  bacteria  Avhieh  are  absorbed  from 
the  primary  focus  rapidly  multiply  in  the  blood,  for  the  organism  is 
not  able  to  produce  enough  protective  substances  to  destroy  the  bacteria 
and  neutralize  the  toxins  (septicaMuia  as  defined  by  bacteriologists). 
The  resistance  of  the  organism  is  so  low  relative  to  the  virulence  of  the 
bacteria  that  there  is  no  inflammatory  reaction  in  the  tissues  ending  in 
pus  formation. 

In  the  general  toxic  infections  (such  as  occur  in  tetanus  and  diph- 
theria) large  quantities  of  toxins  enter  the  circulation.  This  form  of 
infection,  which  can  scarcely  be  distinguished  from  the  bacterial  infec- 
tions except  by  negative  blood  cultures,  occurs  more  freijuently  in  in- 
fections with  the  uncommon  pyogenic  bacteria  and  in  mixed  infections, 
especially  in  mixed  infections  Avith  putrefactive  bacteria. 

There  are  a  number  of  transitions  between  these  two  principal  forms 
of  general  pyogenic  infections. 

It  is  not  necessary  that  each  of  these  ti'ansitional  forms  be  nained, 
and  besides,  it  is  frequently  difficult  to  apply  a  term  which  accurately 
describes  the  condition.  The  terms  which  have  been  inti'oduced  into  the 
nomenclature  of  the  different  forms  of  general  infections  have  been 
variously  interpreted  by  different  authorities,  and  this  has  ri'sulted  in 
considerable  confusion;  for  exam])le,  riussenbauer  and  Brunner  regard 
sepsis  as  synonjmious  with  putrefaction,  while  Canon  and  Lenhartz  re- 
gard it  as  synonymous  with  general  pyogenic  infection.  Von  Kahldcn 
regards  septicaemia  as  synonymous  with  toxa'mia  (regardless  of  whether 
it  is  due  to  pyogenic  or  putrefactive  bacteria).  In  order  to  avoid  con- 
fusion and  simplify  matters.  Lexer  employs  the  term  putrid  infection 
and  general  putrid  infection  for  local  inflammatory  process  character- 
ized by  putrefactive  changes  and  the  general  symptoms  following  them. 

While  the  terms  pyaemia,  septiesemia,  sapr^emia,  etc.,  are  not  used  in 
the  German  edition  of  this  book,  it  seems  best  to  explain  the  significance 
of  these  terms,  which  have  become  so  firndy  established  in  ^Vmerican 
medical  literature.     The  general  pyogenic  infection  with  metastases  as 


282  WOUND    INFECTIONS    PRODUCED   BY   BACTERIA 

used  by  Lexer  is  synonymous  with  pyaniia;  general  pyogenic  infection 
without  metastases  with  septicoimia,  and  general  putrid  infection  with 
saprcemia. 

(a)     GENERAL   PYOGENIC   INFECTIONS   WITH   METASTASES 

(PYiEMIA) 

Bacteria  Most  Commonly  Found. — Any  variety  of  pyogenic  bacteria 
from  any  inflammatory  focus  is  able  to  produce  metastatic  suppuration 
in  the  body.  Staphylococci  are  found  most  frequently  in  these  general 
infections,  and  next  in  order  of  frequency,  streptococci,  which  tend  to 
produce  suppuration  of  the  joints  and  serous  membranes,  phlegmons,  and 
erysipelas.  Pneumococci,  gonococci,  colon  and  typhoid  bacilli  (after 
typhoid  fever)  are  found  less  frequently  than  staphylococci  and  strep- 
tococci. Mixed  infections  with  the  staphylococci  and  streptococci  are 
relatively  common. 

Most  Common  Sources  of  Infection. — The  bacteria  may  be  absorbed 
from  any  inflannnatory  focus  or  may  be  carried  from  diseased  vessels  in 
the  form  of  bacterial  or  infected  emboli  into  the  general  circulation. 
The  most  common  sources  of  infection  are :  1.  Infected  wounds.  2.  Local 
inflammatory  processes.  3.  Infected  ulcers.  Operation-wounds  at  the 
present  time  are  rarely  the  source  of  general  infection,  although  in  pre- 
antiseptic  times  severe  general  infections  were  exceedingly  common  sec- 
ondary to  infected  operation-wounds. 

Infected  wounds  with  recesses  and  pockets,  the  tissues  of  which  are 
infiltrated  with  blood  and  necrotic  (e.  g.,  contused  and  lacerated  wounds, 
large  wounds  of  the  soft  tissues  surrounding  complicated  compound 
fractures,  bites  inflicted  by  mad  animals,  deep  wounds  following  explo- 
sions and  machine  injuries,  and  the  inner  surface  of  the  uterus  after 
delivery),  are  most  frequently  followed  by  general  infections.  Putre- 
factive bacteria,  which  are  often  associated  with  pyogenic  bacteria  in 
infections  of  this  character,  increase  the  virulence  of  the  latter  and  favor 
the  develoi)ment  of  general  infections. 

Any  local  inflannnatory  process  such  as  a  furuncle,  a  phlegmon,  an 
inflammation  of  a  mucous  membrane  ((^specially  an  angina,  an  em]\yema 
of  one  of  the  accessory  .siinises  of  tlie  nose,  otitis  media),  lymphangitis, 
thrombophlebitis,  haimatogciious  endocarditis,  arthritis,  and  suppurative 
osteomyelitis,  may  be  the  .source  of  a  general  pyogenic  infection. 

Ulcers  of  all  sorts  (tuberculous,  typhoid,  syphilitic,  carcinomatous) 
may  provide  llie  infection  atrium  for  a  general  infection. 

The  So-called  Cryptog^enic  Infections. — Although  there  are  cases  in 
whieli  the  primary  focus  eaiuiot  be  found,  it  is  certain  that  one  exists 
or  has  existed  in  eacii  case.     In  the  cases  of  so-called  cryptogenic  infec- 


GENERAL   TYOGENIC    INFECTIONS  283 

tion  there  may  have  been  a  slight  inflammation  of  a  mucous  membrane 
which  gave  rise  to  but  few  symptoms,  or  a  furuncle  which  has  healed, 
and  although  the  lesion  maj''  have  healed  entirely,  bacteria  may  have 
been  retained  in  the  thrombosed  veins  of  the  area  involved  or  the  lym- 
phatic nodes  which  drained  it  and  later  have  caused  the  general  infection. 

Factors  Favoring  the  Development  of  a  General  Infection. — All  those 
factors  which  favor  the  absorption  of  bacteria  and  their  toxins,  or  the 
setting  loose  of  particles  of  thrombi  or  groups  of  bacteria  in  the  lym- 
phatic vessels  and  veins  favor  the  development  of  a  general  infection. 
The  most  common  are  injuries  and  mechanical  irritation  of  the  wounds, 
which  even  at  the  present  time  are  frequently  not  avoided  in  the  treat- 
ment. 

Trauma  and  other  injuries,  providing  as  they  do  the  locus  minoris 
resistentife,  also  determine  the  localization  of  hti'inatogenous  infections. 
Lacerations,  ha'matomas,  and  circulatory  disturbances  so  reduce  the  re- 
sistance of  the  tissues  that  they  are  no  longer  able  to  destroy,  as  the 
normal  tissues  do,  the  bacteria  which  are  deposited  by  the  blood  stream. 
To  cite  an  example  of  the  lower  resistance  of  tissues  following  an  injury, 
a  subcutaneous  fracture,  a  subcutaneous  or  muscular  hajmatoma  becomes 
infected  during  the  course  of  an  angina  and  suppurates. 

Susceptibility  of  Diiferent  Tissues  and  Viscera. — The  different  tissues 
and  viscera  of  the  body  must  have  some  peculiar  properties,  concerning 
which  but  little  is  known,  which  determine  the  localization  of  ha^na- 
togenous  infections.  For  example,  if  a  small  culture  of  pj'ogenic  bac- 
teria is  injected  into  the  cutaneous  vein  of  an  experimental  animal,  sup- 
purating foci  develop  first  in  the  lungs,  in  which  the  grosser  particles 
which  have  been  injected  are  retained.  Later  foci  develop  in  the  joints 
or  in  young  animals  in  the  bone  marrow,  then  in  the  periosteum  and 
kidneys,  less  fre<iuently  in  the  liver  and  serous  cavities.  Only  after  the 
injection  of  large  amounts  of  a  culture  do  foci  develop  in  other  organs, 
especially  in  the  muscles,  and  finally  in  the  myocardium,  subcutaneous 
tissues,  etc. 

Mechanical  conditions  seem  to  play  an  important  part  in  determining 
the  localization  of  infections,  for  the  bacteria,  especially  if  carried  in 
infected  emboli,  lodge  nlost  fre(iuently  in  very  vascular  organs  (lungs, 
bone  marrow,  synovial  membranes,  kidney,  and  liver).  Bacteria  seem 
also  to  be  deposited  in  tissues  and  viscera  (bone  marrow  and  spleen) 
which  form  large  amounts  of  bactericidal  substances.  They  are  retained, 
and  if  too  many  and  too  virulent  bacteria  are  not  deposited  they  are 
destroyed. 

Symptoms. — Clinically  the  symptoms  of  the  general  reaction  (except- 
ing, of  course,  the  so-called  cry]>togenic  infections)  which  accompany  an 
infected  wound  or  a  local  inflammatory  process  precede  the  symptoms 


I 


284  WOUND    INFECTIONS   TRODUCED   BY   BACTERIA 

of  the  general  infection.  The  fever  accompanying  the  general  reaction, 
which  often  begins  with  a  chill  and  rises  abruptly  or  gradually,  is  called 
ohsorption  fever  to  differentiate  it  from  the  fever  occurring  in  the  gen- 
eral infections  into  which  it  often  passes  imperceptibly.  This  absorption 
fever  should  not  be  regarded,  however,  as  indicative  of  a  general  in- 
fection unless  there  are  other  symptoms  which  usually  occur  in  these 
cases. 

General  infection  with  metastases  is  characterized  by  frequent  chills, 
intermittent  fever,  severe  general  symptoms,  and  the  development  of 
metastases. 

The  disease  begins  with  a  severe  chill,  and  during  the  subsequent 
course  of  the  infection  chills  may  recur  many  times  during  the  day  or 
after  long  intervals.  A  high  temperature  (103°-104°  F.)  which  rises 
abruptly  accompanies  each  chill.  The  temperature  drops  suddenly 
from  three  to  four  degrees  each  day,  especially  in  the  morning,  and  rises 
later  in  the  day,  but  this  rise  is  not  accompanied  by  a  chill.  The  fever 
accompanying  these  infections  is  therefore  usually  of  either  an  inter- 
mittent or  remittent  type.     There  are,  however,  frequent  exceptions. 

Character  of  the  Fever. — The  fever  becomes  continuous  if  there  is  a 
rapid  and  continuous  absorption  of  pyogenic  substances  from  an  exten- 
sive primary  or  secondary  suppurating  focus,  or  if  the  protective  sub- 
stances are  so  reduced  that  the  blood  infection  is  frequently  repeated 
or  becomes  permanent.  These  bactericidal  substances,  when  formed  in 
sufficient  amounts,  destroy  the  bacteria  and  neutralize  the  toxins  so  that 
the  blood  infection  is,  as  a  rule,  transitory  (vide  Fig.  124). 

A  remittent  fever  should  not  be  regarded  as  indicative  of  a  metas- 
tatic infection  unless  there  are  other  symptoms.  A  simple  absorption 
fever  which  is  designated  by  many  authors  as  "  septic  fever  "  or  even 
"  sepsis  "  may  have  a  similar  curve,  as  is  frequently  the  case  in  inflam- 
mations caused  by  streptococci  (vide  Fig.  126). 

One  should  not  conclude,  as,  for  example,  in  erysipelas,  that  there 
is  a  toxic  or  bacterial  blood  infection,  because  there  is  a  continuous  ab- 
sorption fever,  even  if  bacteria  may  be  cultivated  from  the  blood.  So 
long  as  the  other  symptoms  are  wanting  the  fever  is  merely  indicative  of 
a  long  persisting  reaction  of  the  organism  to  the  substances  which  are 
absorbed  from  the  inflammatory  focus. 

Different  types  of  fever  are  produced  by  different  bacteria.  These 
differences  are  so  slight  and  depend  upon  so  many  factors  that  they  have 
no  clinical  value. 

The  general  symptoms  are  malaise,  pain  in  the  extremities,  rapid 
pulse  and  respiration,  dry  tongue,  thirst,  dry  hot  skin  or  profuse  per- 
spii-ation,  licadaclic,  stupor,  delirium,  anorexia,  and  vomiting.  These 
syiii])toiiis  are  eomiuoii  to  the  infectious  diseases. 


GExNERAL   PYOGENIC    INFECTIONS  285 

Associated  with  these  are  symptoms  whieh  also  occur  in  general  in- 
fections withont  metastases:  severe  diarrh(ea,  which  is  caused  by  the 
excretion  of  the  absorbed  toxins  or  metastatic  inflammation  of  the  intes- 
tinal mncons  membrane  due  to  emboli ;  icterus,  which  may  develop  after 
a  few  days,  probably  due  to  the  destruction  of  red  corpuscles  (ha^mo- 
cytolysis)  ;  acute  splenic  swellino-  which  develops  in  this  form  of  infec- 
tion and  in  other  infectious  diseases,  sometimes  produced  by  metastatic 
abscesses ;  alterations  in  the  composition  of  the  blood  shown  by  a  reduc- 
tion in  the  number  of  red  blood  corpuscles,  and  frequently  by  quite  a 
marked  leucocytosis  {vide  Blood  Infection)  ;  and  finally  ulcerative  endo- 
carditis, which,  according  to  Lenhartz,  develops  in  from  one  fourth  to 
one  fifth  of  all  cases  of  general  infection,  especially  in  the  form  accom- 
panied by  metastases.  The  ulcerative  endocarditis  develops  most  fre- 
quently upon  the  left  side  of  the  heart. 

If,  as  is  frequently  the  case,  the  symptoms  of  lung  involvement  due 
to  metastatic  abscesses  and  inflammatory  infiltration  are  most  prominent, 
the  patient  becomes  dyspnoeic,  coughs  and  expectorates  considerable  foul- 
smelling  material,  which  may  difi'er  quite  a  great  deal  in  character.  Fre- 
quently during  the  later  course  of  the  infection  the  physical  findings  of 
a  pleurisy  developing  frcm  a  focus  situated  in  the  periphery  of  the  lung 
may  be  elicited.  The  development  of  an  infarct  of  the  lung  is  indicated 
by  sudden  dyspnoea,  cardiac  weakness,  and  bloody  sputum. 

Involvement  of  the  kidneys  may  not  be  accompanied  by  symptoms 
or  may  be  indicated  by  the  symptoms  of  a  severe  acute  nephritis.  Small 
foci  resembling  an  infarct  in  shape  develop  in  the  cortex.  Striated  foci 
also  develop  in  the  medulla.  The  latter  are  caused  by  the  bacteria  which 
are  filtered  through  the  glomeruli  into  the  uriniferous  tubules. 

One  after  another  of  the  joints,  especially  the  larger  ones,  may  be- 
come afi:'ected.  Sometimes  the  synovitis  dev«^lops  acutely,  sometimes  sub- 
acutely.  The  exudate  may  be  serous,  serofibrinous,  serohivmorrhagic,  or 
purulent.  In  severe  cases  the  inflammation  extends  rapidly  to  the  cap- 
sule and  the  articular  cartilages,  which  are  destroyed.  Besides  these 
joint  metastases,  there  is  often  found  (especially  in  general  infections 
due  to  gonococci)   inflammation  of  the  tendon  sheaths  and  bursas. 

Frequently  small  and  large  ha'morrhages  occur  in  the  eye,  the  retina 
becomes  necrotic;  the  crystalline  lens  becomes  clouded  or  suppurates, 
iridocyclitis  and  panophthalmitis  develop. 

The  serous  membranes,  pia  mater,  pleura,  pericardium,  peritoneum, 
become  infected  through  the  blood  or  by  extension  of  some  focus  in  the 
brain,  hnig,  myocardium,  or  abdominal  viscera.  In  rare  cases  the  tunica 
vaginalis  testis  becomes  inflamed.  As  a  rule,  the  inflammation  is  sec- 
ondary to  s(mie  focus  in  the  testicle  or  epididymis. 

Muscle  foci  sometimes  produce  circumscribed  abscesses,  at  other  times 


286  WOUND    INFECTIONS   rilODUCED   BY   BACTERIA 

progressive  phlegmons.  These  foci  are  especially  numerous  in  staphy- 
lococcic infections,  and  often  precede  the  development  of  subcutaneous 
abscesses.  In  chronic  cases  frequently  sixty  to  one  hundred  subcutaneous 
and  muscular  abscesses  develop  and  must  be  opened.  The  subcutaneous 
tissue  may  be  the  seat  of  progressive  phlegmons,  particularly  if  the  in- 
fection is  due  to  streptococci,  while  metastatic  erysipelas,  as  well  as  a 
scarlet-fever-like  erythema,  small  hemorrhages,  herpes,  and  pustules  may 
develop  in  the  skin. 

The  metastases  stand  in  different  relations  to  the  primary  focus.  The 
metastases  are  spoken  of  as  secondary,  tertiary,  etc.,  depending  upon 
whether  they  have  developed  from  the  primary  or  a  metastatic  focus. 
An  ulcerative  endocarditis  is  very  frequently  the  origin  of  such 
metastases. 

A  general  infection  with  metastases  may  pursue  an  acute  or  chronic 
course.  The  acute  forms  prove  fatal  in  a  short  time  if  the  formation 
of  metastases  is  not  prevented  by  proper  treatment  of  the  wound  which 
is  in  the  infection  atrium.  The  greater  the  number  of  metastatic  foci, 
the  greater  are  the  dangers  of  a  permanent  blood  infection.  Bacteria 
and  their  toxins  pass  into  the  blood  from  all  these  foci.  >, 

Chronic  Forms  of  Infection. — The  chronic  forms  which  are  sometimes 
observed  in  staphylococcic  infections  may  continue  for  weeks  and  months. 
In  rare  cases,  if  there  is  no  severe  infection  of  the  viscera,  recovery  may 
occur  even  after  a  number  of  muscular  and  subcutaneous  abscesses  and 
suppurative  arthritis  have  developed. 

Prognosis. — The  prognosis  is  gravest  in  the  acute  cases  with  multi- 
ple metastases  and  pathological  changes  in  the  important  viscera.  Heal- 
ing may  occur  in  the  chronic  cases  with  a  limited  number  of  metastases. 

Diagnosis. — The  diagnosis  in  advanced  cases  is  not  difficult,  espe- 
cially if  the  original  inflannnatory  focus  is  still  present.  In  the  crypto- 
genic cases  the  pathological  changes  in  the  viscera  often  are  most  promi- 
nent and  the  disease  may  be  mistaken  for  suppurative  nephritis,  cere- 
b]'os])iiial  meningitis,  or  endocarditis  occurring  in  the  course  of  acute 
arti(!ular  rheumatism.  If  the  symptoms  are  not  pronounced,  acute  mil- 
iary tuberculosis  and  typhoid  fever  must  be  considered. 

Blood  Examination. — Examination  of  the  metastatic  foci  and  of  the 
blood  is  most  impnitjint  in  making  a  diagnosis.  Bacteria  may  be  tlem- 
onstrated  in  the  blood  in  a  large  number  of  cases  shortly  after  the  chill 
with  the  methods  which  are  (nnployed  at  the  ])ivsent  time.  The  finding 
of  pyogenic  l)Mctei'ia  excludes  acute  ai'ticuhii-  i-heumatism,  for  in  rheu- 
matism proper  l)a('teria  are  never  found   (Lenhart/). 

Treatment.- — The  fii-st  indicjition  in  the  treatment  of  geni^ral  infec- 
tion with  metastases  is  to  pi-event  furtlier-  infection  of  the  blood.  Often 
this  is  accomplished  by  thorough  eN])osure  of  the  primaiy  focus  accord- 


GENERAL   PYOGENIC   INFECTIONS  287 

ing'  to  the  genor.il  i-ulcs  jilrcjidy  uivcn  (ridi  ]>.  198).  Often  ;iiii|>ut;i- 
tion  of  the  diseas(>(l  extremity  or  extirpation  of  the  diseased  viseus  (e.  jr., 
kidney)  is  recjuired.  In  otiier  cases  the  extension  of  the  infection  by 
the  separation  of  thrombi  in  an  inflamed  vein  is  prevented  by  the  liga- 
tion of  the  larf>e  trunks,  e.  ix.,  ligation  of  the  internal  jiijinlar  vein  in 
carbuncle  of  the  face  with  thrombophle])itis  of  the  anterior  facial  vein 
or  in  thrombosis  of  the  transverse  sinus  secondary  to  otitis  media;  liga- 
tion of  the  long  saphenous  vein  in  thromljophlebitis  of  its  branches  (cf. 
Suppurative  Phlebitis) . 

The  second  indication  is  to  expose  all  demonstrable  and  accessible 
metastatic  foci  and  to  treat  them  according  to  the  general  rules. 

The  third  indication  is  to  improve  the  general  condition  of  the  pa- 
tient by  a  nutritious  but  light  diet  and  to  stimulate  the  heart  (particu- 
larly by  subcutaneous  injections  of  camphor  oil)  when  it  begins  to  fail 
(cf.  General  Treatment  of  Blood  Infections,  p.  291), 

(b)     GENERAL   PYOGENIC   INFECTION   WITHOUT  METASTASES 

(SEPTICAEMIA) 

In  the  general  pyogenic  infection  without  metastases,  the  blood  and 
with  it  the  entire  organism  is  tiooded  with  bacteria  and  their  toxins. 
The  bacteria  multiply  rapidly  in  the  blood  and  the  tissues.  A  bacterial 
infection  develops  when  the  bactericidal  substances  are  no  longer  pro- 
duced, or  in  small  amounts  only,  or  M^hen  the  invading  bacteria  are  espe- 
cially virulent. 

Factors  Favoring  Development  of  General  Infection. — The  factors 
which  favor  and  cause  the  development  of  this  form  of  infection  are 
the  same  as  described  in  the  general  infection  with  metastases  with  the 
following  exceptions:  1.  In  the  pure  type  the  infection  is  not  carried  by 
emboli.  2.  The  development  of  a  primary  intlanunatoiy  focus  before  the 
beginning  of  the  general  infection  is  not  essential.  The  local  and  gen- 
eral symptoms  may  develop  simultaneously  after  tlie  infection  has  been 
introduced  (e.  g.,  after  injury  received  while  performing  a  post-mortem 
examination). 

The  streptococcus  pyogenes  is  found  most  fretiuently  in  this  type  of 
infection.  The  streptococcus  may  enter  the  blood  not  only  from  pyo- 
genic, but  from  putrefactive  wound  infections  as  well.  Its  virulence  is 
increased  by  symbiosis  with  putrefactive  bacteria.  Staphylococci,  pneu- 
mococci,  colon  bacilli,  and  other  bacteria  are  more  rarely  the  cause  of 
general  infections.  Pneumococci  are  found  most  frequently  in  general 
infections  following  pneumonia.  In  mixed  infections  with  the  strei)to- 
coccus  and  some  other  variety  of  pyogenic  bacteria,  the  former  alone, 
as  a  rule,  passes  into  the  blood. 


288 


WOUND    L\Fi:CTIOXS   PRODUCED   BY   BACTERIA 


Relative  Frequency  with  which  Dilferent  Bacteria  Cause  Metastatic 
Suppuration.^ — A  good  idea  may  be  had  from  Lenhart/'s  statistics  of 
tlie  relative  fre({iiency  with  which  general  infections  produced  by  the 
different  bacteria  pursue  their  course  with  and  without  metastases. 
For  sake  of  convenience  the  cases  are  arranged  in  the  following  way : 


Bacteria. 


Streptococci 

Staphylococci 

Pneumococci 

Bacterium  coli  commune 


No.  of  cases. 


100 
22 
20 


Without 
Metastases. 


65% 

5% 
75% 
78% 


With 
Metastases. 


35% 
95% 
25% 
22% 


The  general  pyogenic  infection  is,  as  a  rule,  a  bacterial  one,  as  the 
blood  contains  large  numbers  of  rapidly  multiplying  bacteria  which 
produce  toxins.  If  bacteria  cannot  he  demonstrated  in  the  blood,  and 
if  the  primary  infection   is   purely   pyogenic,   one  may   conclude  that 

the  s.ymptoms  are  produced  by 
toxins  which  are  absorbed  from 
the  primary  focus.  This  form, 
known  as  the  general  toxic  in- 
fection, is  commonly  found  in 
putrefactive  infections,  but  is 
the  exception  in  pyogenic  in- 
fections. 

Symptoms. — The  symptoms 
may  develop  within  a  few 
hours,  often  after  an  apparently 
in.significant  injury.  The  dis- 
ease begins  with  a  chill,  high 
fever,  and  severe  general  symp- 
toms (especially  after  injuries 
received  in  post-mortem  exam- 
inations of  patients  dying  of 
acute  supi)urative  or  general 
infection).  Sometimes  the 
symptoms  develop  gradually 
nfter  an  absorption  fever,  re- 
sulting from  a  local  suppura- 
tive inflammation  (e.  g.,  phleg- 
mon, peritonitis,  arthritis,  osteo- 
myelitis), has  pei-sisted  for  some 
time.     Then  there  is  nothing  to 


h'mnldieilsfiiii 

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4 

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7 

8 

9 

10 

Ho 
W.0 
39,0 
38ft 
37,0 
36.0 

R 

1 

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1 

H 

-f- 

t4- 

m 

m 

m 

m 

4\ 

4 

1 

f-\ 

^ 

NH 

m 

n 

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/ 

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J- 

y — 

J— 

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7 

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— V- 

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Fig.  122. — Infection  Fohming  Metastases 
(Staphylococcus  Aureus  Found  in  Local 
AND  Metastatic  Foci)  Following  Suppu- 
hative  Thrombophlebitis  Involving  the 
Long  Saphenous  and  Femoral  Veins  Sec- 
ondary to  a  Varicose  Ulckr  op  the  Leg. 
])oath  on  tontli  day  following  admission  to 
the  hospital.  Post-rnortpm  examination,  ab- 
scesses of  the  liings,  pleurisy,  abscesses  in  the 
mu.sclcs,  foci  in  the  kitlneys,  metastases  in 
two  of  the  joints. 


GENERAL   PYOCjEXIC   INFECTIONS 


2S9 


indicate  when  the  general  infection  begins,  for,  as  a  rnle,  there  is  no 
chill  in  these  cases.  All  the  symptoms  which  occur  in  infectious  dis- 
eases may  be  found  in  this  type  of  infection.  The  temperature  continues 
high  (104°  F.  and  higher),  with  but  little  variation,  ^°  to  1°.  Before 
death  the  patient  may  pass  into  collapse. 

In  the  beginning  the  symptoms  are  depression,  weakness,  restless- 
ness, cramplike  pains  in  the  extremities,  anorexia,  nausea,  and  vomit- 
ing. The  pulse  and  respiration  then  become  more  rapid,  and  cerebral 
symptoms  (headache,  delirium,  coma,  stupor)  develop.  A  hot  dry  skin, 
dry  tongue,  cracked  lips,  great  thirst,  small 
amounts  of  concentrated  urine  rich  in  albumin, 
a  persistent,  at  times,  bloody  diarrhea,  cyanotic 
appearance,  icterus,  pustular  eruption,  or  one 
resembling  scarlet  fever  or  urticaria,  small 
haemorrhages  into  the  skin  (petechije),  which 
are  caused  by  diapedesis  of  blood  through  the 
walls  of  the  capillaries  altered  by  toxins,  splenic 
swelling,  involuntary  discharge  of  fa?ces  and 
urine,  tendency  to  formation  of  bedsores  over 
sacrum,  trochanter,  and  heel  complete  the  clin- 
ical picture.  The  heart  gradually  fails  and 
death  occurs. 

Appearance  of  the  Wound. — The  appearance 
of  the  wound  is  characteristic.  The  wound 
surfaces,  which  are  dry  and  discolored,  are 
covered  with  a  membrane,  resulting  from  a 
superficial  necrosis  of  the  tissues  and  a  fibrin- 
ous exudate  which  contains  bacteria.  Ragged 
accidental  wounds  and  smooth  incisions  have 
this  same  appearance.  The  wound  surfaces  are 
no  longer  able  to  secrete  pus  or  form  granu- 
lation tissue.  If  such  a  wound  is  adjacent  to 
a  subcutaneous  fracture,  frequently  a  suppura- 
tive inflammation  develops  in  the  latter. 

Changes  in  the  Blood. — As  a  rule,  there  is  a 
marked  reduction  in  the  number  of  red  cor- 
puscles (Grawitz  observed  in  one  case  a  rediic- 
tion  of  ninety  per  cent). 

Large  amounts  of  albumin  are  lost  and  the  blood  becomes  liydramiic. 

As  a  rule,  there  is  no  leucoeytosis.  The  vessel  walls  are  altered  in 
the  severe  cases,  and  spontaneous  haemorrhages  into  the  skin,  sei'ous  mem- 
branes, conjunctiva,  retina,  and  bone  marrow  occur  (luvmorrhagic  general 
infection). 


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Fig.  123.  —  General  Pyo- 
genic Infection  With- 
out Metastases  (Strep- 
tococci in  the  Pus  and 
Circulating  Blood)  Fol- 
lowing A  Seropurulent 
Phlegmon  of  the  Sheath 
of  the  Long  Flexor 
Tendon  of  the  Thumb, 
Secondary  to  a  Punc- 
tured Wound  of  the 
Thumb.  MuUiplc  and  ex- 
tensive incisions.  Death 
on  the  third  day  with  ab- 
rupt fall  of  temperature. 


290 


WOUND    INFECTIONS   rKODlJCI':D   BY    BACTERIA 


Transitional  Forms. — In  the  transitional  forms,  which  are  not  rare, 
there  are  a  number  of  other  symptoms.  These  symptoms,  which  gener- 
ally begin  with  a  chill,  vary,  depending  npon  the  position  of  the  metas- 
tatic inflammation.     They  are  caused  in  part  by  an  endocarditis. 

Prognosis. — As  a  rule,  the  disease  runs  a  rapid  course.  The  severest 
cases  terminate  fatally  in  one  or  two  days  (particularly  puerperal  in- 
fections) (Fig.  128).  Frequently  there  is  some  improvement  after 
operation,  such  as  incision  of  the  phleguion,  amputation  of  the  infected 

extremity,  etc.  After  a  few  days,  how- 
ever, the  disease  may  progress  with 
renewed  vigor,  indicating  how  futile 
operative  interference  has  been.  When 
the  disease  is  well  advanced,  it  is  sel- 
dom possible  to  save  the  patient. 

Diagnosis, — The  diagnosis  is  not 
difficult  when  the  symptoms  are  pro- 
nounced. Repeated  blood  examina- 
tions prevent  mistaking  this  disease 
for  typhoid  fever  and  miliary  tuber- 
culosis. It  is  most  difficult  to  differ- 
entiate between  scarlet  fever  with 
secondary  streptococcic  infection  and 
a  general  streptococcic  infection  with 
a  scarlatiniform  exanthem. 

The  diagnosis  is  based  in  the  be- 
ginning upon  the  severity  of  all  the 
symptoms,   and   not   upon   a   positive 
blood  finding  alone.     It  is  frequently 
difficult  to  make  a  diagnosis  between 
a    general    infection    and    saprtemia. 
If  the   daily  blood  examinations  are 
positive,   and   bacteria   are   found  in 
large  numbers,  the  diagnosis  of  gen- 
eral   infection    may    be   made.      The 
characteristic      appearance      of      the 
wound  and  the  fre(|uent  absence  of 
leucocytosis  indicate  that  the  resist- 
ance of  the  patient  is  greatly  reduced, 
'^^riierc    is   little   clinical    difference 
Ix'lwccn  a  general  pyogenic  and  a  pu- 
trefactive   infection.      The   symptoms   and    tiie   clinical    coui'se   ai-e   the 
same.     Tlie  chief  distinction  is  lliis:  1liat  tlie  local  focus  presents  in  one 
snp])Uiat  ive,  in  llie  ollief  |)ntrefactive  changes.     It  frequently  happens, 


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Fig.  124. — Infection  Forming  Metas- 
tases WITH  Transition  into  a 
General  Blood  Infection.  Caused 
BY  Streptococci  Following  an  In- 
fection OF  the  Synovial  Sheath  of 
THE  Flexor  Tendons  of  the  Little 
Finger  and  Forearm  Secondary 
to  a  Crushing  Injury.  First  day: 
fall  of  fever  after  incision.  Second 
day:  chill  followed  by  pain  in  the 
knee  joint  (.seropurulent  synovitis). 
Fifth  day:  streptococci  numerous 
in  the  blood,  in  the  exudate  re- 
moved from  the  joint,  and  in  the 
pus  discharged  from  the  phlegmon. 
Seventh  day:  streptococci  very  nu- 
merous in  the  blood.  J'^ighth  day: 
death. 


GENERAL   PYOGENIC   INFECTIONS 


291 


however,  that  a  general  streptocoecic  iiifectioii  develoi^  from   a  i)ulre- 
factive  focus. 

The  prophylactic  treatineiit  has  already  been  discussed  in  the  chap- 
ter dealing  with  the  treatment  of  pyogenic  infections  {vide  p.  201). 


Fig.  125. — Infection  Forming  Metastases  Following  Carbuncle  of  the  Upper  Lip; 
Atypical  Fever  from  I'ourth  to  Tenth  Day.  First  day:  incision.  Second  and 
third  days:  chills.  Third  day:  large  incision,  opening  of  the  anterior  facial  vein 
which  contained  a  suppurating  thrombus  and  ligation  of  the  internal  jugular  vein. 
Fourth  to  tenth  day:  absorption  fever,  gradually  falling  as  the  conditions  in  the  wound 
improve  and  tlie  inflammation  subsides.  Hf  teenth  day :  chill  and  development  of  small 
abscess  in  an  infected  muscle.     Recovery. 

The  chief  indication  is  to  expose  by  early  incision  or  to  remove  by 
amputation  or  joint  resection  the  original  focus.  This  is  only  possible 
if  the  case  is  seen  early.  The  expectant  treatment  should  not  be  em- 
ployed (vide  Phlegmon,  p.  212), 

The  remaining  treatment  is  palliative.  Narcotics  are  given  for  the 
cerebral  symptoms.  Comatose  and  delirious  patients  slioiihl  be  fed  arti- 
ficially. The  strength  of  the  heart  must  be  sustained.  Subcutaneous 
injections  of  physiological  salt  solution  (0.9  pei-  cent)  act  more  i-ap- 
idly  and  favorably  than  any  other  agent.  In  adults  1  to  2  1.,  in  children 
200  c.c.  may  be  given  one  or  many  times  daily.  It  improves  the  general 
condition,  increases  the  excretion  of  urine,  and  in  this  way  favors 
the  excretion  of  the  toxins.  Serum  treatment  has  nu't  with  as  little 
success  as  the  injection  of  bactericidal  substances,  such  as  sublimate 
(Bacelli  and  Kazmarsky)  and  silver  preparations  (Crede),  into  the 
blood.     Brunner  and    Cohn   have   demonstrated   that   the   latter   have 


292 


WOUND    INFECTIONS   PRODUCED   BY    BACTERIA 


no    action   when   employed   in   the   treatment   of    experimental    general 
infections. 

Literature. — B.  Blohm. — Ueber  Vereiterung  subkutaner  Frakturen.  I.-D.  Berlin, 
1898. — K.  Brunner.  Wundinfektion  und  Wuiulbehandlung.  Part  III:  Die  Begriffe 
Pyamie  und  Sephthamie  im  Lichte  der  bakteriologischen  Forschungsergebnisse.  Frau- 
enfeld,  1899; — Ueber  das  losliche  Silber  und  seinen  therapeutischen  Wert.  Fort- 
schritte  d.  Mediz.,  1900,  No.  20.— Busse.  Ueber  Sacharomycosis  hom.  Virchows 
Archiv,  Bd.  140,  1895,  p.  23. — E.  Cohn.  Ueber  den  antiseptischen  Wert  des  Argentum 
coUoidale  Crede  und  seine  Wirkung  bei  Infektionen.  I.-D.  Konigsberg,  1902.— Gussp?).- 
bauer.  Sephthamie,  Pyohjiniie  und  Pyose})hthaniie.  Deutsche  Chir.,  Stuttgart,  1882. 
— Hentschel.  Beitrag  zur  Lehre  von  der  Pyiiniie  und  Sepsis.  Festschr.  f.  Benno 
Schmidt,  Leipzig,  1896,  p.  12L — v.  Knhlden.  Ueber  Septikamie  und  Pyamie.  Zen- 
tralbl.  f.  Pathol.,  1902,  p.  783. — Muscatdlo  und  Ottaviano.  Ueber  die  Staphylokok- 
ken  pyamie.  Virchows  Arch.,  Bd.  1G.3,  1901,  p.  212  and  Lit.,  p.  255. — Further  Lit., 
p.  261. 

Blood  Cultures. — Blood  examinations  made  during  life  should  deter- 
mine the  variety  of  bacteria  in  the  blood  and  give  some  idea  as  to  their 

number. 

Aseptic  prepara- 
tion of  the  field  sur- 
rounding the  vein 
from  which  the  blood 
is  to  be  taken  must 
be  as  nearly  perfect 
as  possible.  In  Sitt- 
mann's  method  the 
skin  covering  the 
median  basilic  vein 
is  thoroughly  steril- 
ized and  a  slight 
venous  stasis  is  pro- 
duced by  applying 
an  elastic  constrictor 
loosely      about      the 

Fig.  126. — Absorption  Fever  (with  Severe  Symptoms,  with-  upper  arm  near  the 
OUT  Chii-i,s)  Oct'iTURiNO  in  a  Pitrtilent  Arthritis  of  the  jixilla.  In  children 
Knee  Which  foi, lowed  a  Streptoc9ccic  Osteomyeliiis 
Involving  the  Articxtlar  I'^nu  op  the  Femur.  Fourth 
day:  incision  of  the  joint.  Fifth  day:  laying  open  of  the 
joint.  Sixtliday:  a  few  streptococci  in  the  blood.  Seventh 
day:  resection  of  the  knee  joint  (metaphyseal  focus  posteri- 
orly whicli  ha<l  ruptured  into  joint).  Ninth  day:  fall  of 
temperature  and  recovery  after  some  weeks  without  a  re- 
currence of  fever. 


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a  branch  of  the  long 
sa{)henous  vein  may 
be  chosen.  A  needle, 
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vaz  syringe — or  bet- 


ter, a  larger  syringe 
which  bolds  ]0  c.c. — is  i)assed  ol)]i(|nely  tln'ougli  the  skin  into  the  vein, 
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PUTREFACTIVE  INFECTIONS  293 

a  rule,  the  piston  of  the  syringe  is  forced  oiilunid  l)y  tlic  ]n'essnre  (tf 
the  blood  stveaining  into  the  needle. 

About  5  c.c.  are  taken  from  small  children,  10  c.e.  or  more  from 
adults.  The  blood  is  carefully  protected  from  contamination  and  is  used 
in  the  following  ways : 

One  c.c.  should  be  injected  iiito  the  .subcutaneous  1issu(^s  or  perito- 
neum of  white  rats.  Death  follows  in  one  or  two  days  if  the  blootl  con- 
tains streptococci  or  pneumococci.  If  it  does  not  occur,  it  is  not  prooL' 
jjositive  that  there  are  no  bacteria  in  the  blood. 

One  c.c.  is  poured  into  a  flask  containing  10  c.c.  of  gelatin,  and  the 
gelatin  then  liquefied  by  warming  the  flask  over  a  water  bath.  After 
the  blood  and  gelatin  are  thoroughly  mixed,  the  mixture  is  poured 
into  a  sterile  Petri  dish.  If  kept  at  22°  C.  in  an  incubator  or  at  room 
temi)erature  colonies  develop  in  from  twelve  to  twenty-four  hours  if 
bacteria  are  present.  The  number  of  colonies  in  1  qcm.  gives  a  good  idea 
of  the  total  number  of  bacteria.  The  variety  of  bacteria  may  l)e  deter- 
mined by  inoculations  or  by  microscopic  examination. 

One  c.c.  of  blood  may  be  mixed  with  10  c.c.  of  nutrient  bouillon. 
If  kept  at  37°  C.  in  the  incubator  even  a  few  bacteria  multii)ly  so  ra])- 
idly  in  twelve  hours  that  they  may  be  transferred  to  agar  or  gelatin 
with  a  platinum  loop.  A  luxurious  growth  can  be  obtained  in  this  way. 
Amprobic  cultures  media  must  be  used  when  the  primary  infection  is 
caused  by  putrefactive  bacteria. 

Blood  examinations  made  after  death  are  of  little  value.  Bacteria 
pass  from  the  suppurating  focus  or  from  the  intestines  into  the  blood 
during  the  death  agony.  In  cases  in  which  the  cultures  made  during 
life  were  negative,  the  conclusicm  may  be  drawn,  if  large  numbers  of 
bacteria  are  found  in  the  blood  immediately  after  death,  tliat  a  few 
were  present  during  life. 


CHAPTER    Aa 

PUTREFACTIVE   INFECTIONS 

(a)     PUTREFACTIVE   WOUND   INFECTIONS   AND   GENERAL 

INFECTIONS 

As  suppurative  inflammation  is  the  chief  characteristic  of  the  activ- 
ity of  pyogenic  bacteria,  so  putrefactive  inflammation  with  the  forma- 
tion of  an  exudate,  M'hich  in  the  beginning  is  seroluvmorrhagie  in  char- 
acter and  later  becomes  discolored  and  foul  smelling,  contains  gas  and 
is  associated  with  putrefacticyn  or  gangrene  of  the  tissues,  is  indicative 
of  infections  with  putrefactive  bacteria. 
20 


294  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

Allied  Processes. — Clinically  there  are  a  iiiiniber  of  proc(>sses  which 
are  closely  allied ;  sometimes  the  formation  of  gas  being  the  most  promi- 
nent feature  of  the  clinical  picture  (gas  phlegmon)  ;  at  other  times  gan- 
grene (noma,  hospital  gangrene). 

Secondary  Infections. — Secondary  infections  with  pyogenic  bacteria, 
most  frequently  the  streptococcus,  are  common  in  these  cases.  The 
clinical  picture,  however,  of  putrefactive  inflammation  is  always  due  to 
the  putrefactive  bacteria,  even  when  there  is  a  secondary  infection.  The 
general  infection  following  the  local  infection  is  apparently  often  purely 
pyogenic  in  character,  as  streptococci  are  frequently  found  in  the  blood. 
It  cannot  be  denied,  however,  that  many  of  the  severe  general  symp- 
toms are  due  to  the  absorption  of  the  toxic  products  elaborated  by  the 
putrefactive  bacteria.  The  term  pyosepthjpmia  w^as  formerly  applied 
to  these  mixed  forms  of  general  putrefactive  and  pyogenic  infections; 
we  will  avoid  the  use  of  this  term  for  reasons  already  given  (p.  281). 
The  character  of  the  inflammation  at  the  infection  atrium  is  the  best 
index  as  to  the  character  of  the  general  infection.  If  the  local  infec- 
tion is  of  a  jHitrefactive  character,  the  general  infection  should  be  re- 
garded as  putrefactive,  even  if  streptococci  are  found  in  the  blood,  as 
it  is  impossible  to  demonstrate  the  toxic  products  which  are  formed  by 
the  activity  of  putrefactive  bacteria.  If,  however,  the  local  inflamma- 
tion is  suppurative  in  character,  the  general  infection  should  be  re- 
garded as  pyogenic,  even  if  putrefactive  bacteria  may  be  demonstrated 
in  the  local  inflammatory  focus. 

The  bacilli  of  the  colon  group  form  a  peculiar  intermediate  group  be- 
tween the  pyogenic  and  putrefactive  bacteria ;  depending  upon  their  action 
they  are  sometimes  classed  with  the  former,  sometimes  with  the  latter. 

Relation  between  Putrefaction  and  Fermentation;  Substances  pro- 
duced by  Putrefaction. — Putrefaction  is  closely  allied  to  fermentation; 
the  former  is  a  reduction,  the  latter  an  oxidation  process.  [Putrefaction 
may  be  roughly  considered  as  a  form  of  fermentation  of  albuminous 
and  albuminoid  matter.  It  seems  that  the  first  change  is  peptonization, 
effected  in  pa)'t  by  the  peptonizing  enzymes  possessed  by  most  organ- 
isms of  decomposition.  The  peptonized  substances  are  then  further 
changed  and  split  up;  amido-derivatives  (especially  amido-acids),  aro- 
matic bodies,  and  sulpho-aeids  are  next  formed,  and  these  are  further 
s])lit  up,  indol  being  among  the  final  products. 

The  list  of  substances  which  may  appear  during  putrefaction  is 
very  extensive;  it  e(mtains  among  the  gases  CO,,  H,  IL,S,  and  0114; 
among  the  fatty  acids  acetic,  butyric,  and  valerianic  acids,  besides  vari- 
ous amido-compounds,  amins,  indol,  skatol ;  })odies  of  the  aromatic  series; 
various  ptomjiiiis;  basic  comp(mnds,  etc.,  the  chemical  combinations  vary- 
ing (|ii;ili1;i1i\(Iy  and  (luaiititatively  with  the  peculiar  bacterial  species 


PUTREFACTIVE    INFIX  TIONS  295 

concerned  and  with  the  decomposing  medium.  The  result  of  putrefac- 
tion in  all  cases  is  the  decomposition  of  highly  complex  substances  into 
others  of  simpler  and  more  assimilable  structure.  It  is  especially  under 
amerobic  conditions  that  the  odor  of  putrefaction  is  observed. —  (Allbutt's 
System  of- Medicine,  vol.  i,  p.  529.)] 

There  are  formed  in  putrefaction,  in  addition  to  tlie  mctaholie  prod- 
ucts of  the  bacteria,  complicated  toxic  and  nontoxic  substances,  the  so- 
called  putrefactive  alkaloids  or  ptonuiins  (Selmi)  and  the  toxic  albu- 
minous substances  or  toxalbumins. 

Investigations  as  to  the  nature  of  the  active  substances  in  the  putre- 
factive exudates  were  made  long  before  the  most  important  bacteria 
were  discovered.  Panum  (1855)  obtained  a  poisonous  extract,  von  Berg- 
mann  and  Schmiedberg  (1868)  obtained  a  crj'stalline  body,  sepsin,  and 
were  the  first  to  suggest  that  it  was  to  be  regarded  as  the  direct  secretion 
product  of  bacteria,  and  not  as  a  decomposition  product  of  the  albumins. 

Nencki  (1876)  was  the  first  to  isolate  a  pure  ptonuiin.  Brieger 
(1885-86),  employing  improved  chemical  methods,  isolated  a  number 
of  nitrogenous  bases  from  putrefying  masses.  To  the  poisonous  pto- 
maius,  to  which  he  gave  the  generic  term  toxins — a  name  now  applied 
only  to  poisons  secreted  by  living  bacteria — belong  peptotoxin,  neurin, 
musearin,  etc.,  while  other  bases,  such  as  neuridin,  gadiuin,  putrescin, 
cadaverin,  saprin,  cholin,  mydatoxin,  mydin,  are  nontoxic,  or  only  toxic 
when  administered  in  large  amounts. 

The  putrefactive  have  not  been  as  thoroughly  studied  as  pyogenic 
micro-organisms.  This  is  partly  due  to  the  fact  that  putrefactive  infec- 
tions are  rare  at  the  present  time,  because  of  the  methods  employed  in 
treating  wounds,  and  partly  to  the  fact  that  large  numbers  of  sapro- 
phytes are  deposited  in  necrotic  tissue,  and  it  is  difficult  to  differentiate 
between  these  and  the  putrefactive  bacteria. 

Bacteria  of  Putrefaction. — The  principal  causes  of  putrefactive  wound 
infections  belong  to  the  large  group  of  bacteria,  of  which  the  proteus 
and  colon  bacilli,  the  bacillus  aerogenes  capsulatus,  and  the  bacillus  of 
malignant  oedema  are  the  most  important. 

Proteus  Vulgaris. — Hauser  described  under  the  name  of  proteus  vul- 
garis a  form  of  bacillus  which  frequently  occurs  in  putrefying  animal 
tissues.  This  bacillus  is  from  1.2  to  4  /a  in  length,  and  has  an  aver- 
age width  of  0.6  /x.  It  is  provided  with  numerous  tlagella,  and  is 
therefore  actively  motile;  does  not  stain  with  anilin  dyes,  and  only 
occasionally  by  Gram's  method. 

It  is  a  facultative  ancerobe  and  grows  upon  ordinary  culture  media. 
If  there  is  a  free  access  of  air  gelatin  is  rapidly  li(iuefied  and  foul- 
smelling  substances,  such  as  indol  and  sulphui-cttcd  hydrogen,  are 
formed.     When  air  is  excluded  the  growth  is  nuich  the  same,  but  the 


296  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

gelatin  is  then  not  liquefied.  Gas  is  formed  and  an  acid  reaction  devel- 
ops in  culture  media  containing  grape-sugar;  urea  is  transformed  in 
carbonate  of  ammonia. 

Gelatin  cultures  are  most  characteristic.  Small  depressions  filled 
with  M'hite  masses  form  rapidly  upon  the  surface  of  the  gelatin.  From 
a  turflike  zone,  which  surrounds  the  depression  resulting  from  lique- 
faction, delicate  processes  composed  of  bacilli,  arranged  in  the  shape 
of  threads,  run  in  all  directions. 

There  is  produced  in  culture  media  a  poisoiKms  alkaloid,  which,  ac- 
cording to  E.  Levy,  is  identical  w^ith  the  sepsin  isolated  by  von  Berg- 
mann. 

Subcutaneous  injections  of  cultures  into  experimental  animals  pro- 
duce abscesses;  intravenous  injections,  toxic  symptoms  and  metastatic 
foci  of  suppuration.  The  bacillus  seems  to  be  able  to  multiply  in  living 
tissues  only  when  the  latter  have  been  injured  by  other  bacteria  or  have 
become  necrotic ;  the  converse  is  also  true,  that  the  proteus  favors  the 
development  of  other  varieties  of  bacteria;  for  example,  streptococci 
and  colon  bacilli. 

The  bacillus  is  very  widely  distributed,  even  occurring  in  the  faeces 
of  healthy  individuals,  and  it  may  easily  be  understood  why  it  so  fre- 
quently gains  access  to  neglected  wounds  and  ulcers. 

In  man  the  proteus  vulgaris  is  found  most  frequently  in  foul-smell- 
ing gangrenous  foci  and  gangrenous  phlegmons.  In  rare  cases  they  are 
the  only  bacilli  to  be  found  in  the  intiammatoi-y  focus,  and  may  even 
invade  the  blood,  and  be  deposited  in  the  different  viscera  (Krogius). 
Usually,  however,  other  bacteria,  such  as  the  colon  bacilli  and  strepto- 
cocci, are  also  found,  and  the  clinical  symptoms  of  the  general  infection 
are  caused  by  the  absorption  of  the  toxic  products  of  the  proteus  com- 
bined with  the  bacterial  blood  infection. 

The  proteus  vulgaris  occurs  with  the  bacterium  coli  commune  very 
fre(iuently  in  decomposing  meat  (van  Ermengem).  When  such  meat  is 
eaten  the  proteus  is  carried  into  the  intestine,  where  it  multiplies  and 
elaborates  its  toxic  products,  causing  diarrhtea,  cholera  nostrans  and  gen- 
eral toxic  infections  (])oisoning  l)y  decomposed  meat,  sausage  poisoning). 

It  also  occurs  with  the  colon  bacillus  in  wounds,  fistukE,  and  ulcers 
about  the  anus,  which  become  infected  tlirough  the  fa'ces.  The  proteus 
vulgaris  may  easily  pass  into  the  ur(>thra  and  l)ladder,  and  even  to  the 
pelvis  of  the  kidney,  causing  cystitis  and  pyelonephritis.  These  infec- 
tions occur  most  frccjucntly  after  catheterization.  They  may  pass  into 
the  genilnl  Iriict  ol'  llic  fcuuilc,  and  ai-e  fi'('(|nen1Iy  found  associated 
with  strcplococci  in  puccpei-al  infections.  They  are  found  in  perito- 
nitis, associated  with  colon  bacilli  and  pyogenic  cocci,  following  intes- 
tinal perforation. 


PUTREFACTIVE   INFECTIONS  297 

The  proteus  may  pass  from  the  intestiiics  ;il()n<2:  the  bile  ducts  to 
the  fjall  l)laddei',  and  in  rai'e  cases  may  be  carried  by  way  of  the  blood 
to  the  different  organs  (strumitis,  Tavel). 

Literature. — Brunner.  Wundinfektion  und  Wundbehamllung.  Frauenfeld,  1898, 
II  and  III. — V.  Ermengem.  Die  pathog.  Bakterien  d.  Fleischvergiftungen.  In  Kolle- 
Wassermanns  Handb.  d.  pathog.  Mikroorganismen,  Bd.  2,  1903,  p.  G37. — Ilauscr.  Ucber 
Faulnisbaktericn  iind  deren  Beziehungen  zur  Septikainie.  Leipzig,  1885. — Horn. 
Ueber  das  Vorkommen  des  Proteus  vulgaris  bei  jauchigen  Eiterungcn.  I.-D.,  Erlangen, 
1897. — Kruse.  Bazillen.  In  Fliigges  Die  Mikroorganismen,  Leipzig,  189G. — E.  Levy. 
Exi)!?rini.  und  Klin,  iiber  die  Sepsinvergiftung  und  ihren  Zusammenhang  niit  Bact. 
proteus.     Arch.  f.  exp.  Path.,  Bd.  34,  1894,  p.  342. 

Bacilli  of  tJte  Colon  Group. — The  bacilli  of  the  colon  group  (Bacillus 
Coli  Communis)  have  already  been  mentioned  in  discussing  pyogenic  bac- 
teria, for  they  not  infrequently  produce  local  and  metastatic  inflamma- 
tory processes  ending  in  pus  formation.  Frequently  they  are  associated 
with  the  proteus  vulgaris  in  wounds  infected  by  faeces,  in  perforative 
peritonitis,  and  in  poi.soning  following  the  ingestion  of  decomposing 
meat.  Not  infrequently  they  are  found  in  gangrenous  foci  associated  with 
pyogenic  cocci.    They  have  been  found  alone  in  cases  of  gas  phlegmon. 

In  general  infections  they  may  be  found  in  large  numbers  in  the 
blood  even  during  life.  [No  significance  should  be  attached  to  the  pres- 
ence of  colon  bacilli  in  the  blood  shortly  before  or  after  death.  It 
has  been  known  for  a  long  time  that  colon  bacilli  pass  into  the  blood 
shortly  before  death,  and  that  they  are  found  in  large  numbers  after 
death.  The  term  agonal  infection  has  been  applied  to  the  blood  infec- 
tions occurring  at  this  time.]  It  is  not  known  why  in  one  case  the  colon 
bacillus  produces  pus  and  in  another  case  foul-smelling  gangrene,  accom- 
panied by  gas  formation.  It  apparently  depends  less  upon  the  variety 
of  the  colon  bacillus  than  upon  the  influence  of  .symbiosis  W'ith  other 
bacteria,  especially  the  proteus,  with  which  it  is  frequently  associated 
in  infections  caused  by  faecal  matter. 

Bacillus  Emphysematosus. — The  bacillus  emphysematosus  (bacillus 
aerogenes  capsulatus)  W'as  found  by  E.  Friinkel  in  four  cases  of  gas 
phlegmon,  three  times  associated  wdth  pyogenic  bacteria,  in  one  case 
alone,  and  accurately  described  by  him  in  1893.  Roson])ach  and  E.  Levy 
had  seen  the  bacillus  earlier  than  this;  Welch  and  Nuttall  had  described 
it  as  the  bacillus  aerogenes  capsulatus  in  1892.  It  has  been  found  in 
the  intestinal  canal  of  man  and  animals;  in  garden  earth  and  tlic  du.st 
of  the  streets  (Hirschberg). 

It  is  an  anaerobic  bacillus,  resembling  closely  the  anthrax  bacillus. 
but  forms  no  spores.  It  stains  wdth  anilin  dyes  and  by  Gram's  method. 
It  grows  upon  gelatin  without  liquefying  it  and  without  forming  gas. 
In  glycerin  agar,  to  which  sodium  formate  has  been  added,  gas  of  the 


298  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

odor  of  hydrogen  siilphid  is  formed,  while  in  glucose  agar  an  odorless  gas 
is  produced. 

Guinea-pigs  develop  aftt'r  subcutaneous  injections  a  nonsuppurative 
inflammation,  ending  in  gangrene  and  accompanied  by  the  formation  of 
odorless  gases.  A  foul-smelling  purulent  exudate  develops  as  in  the 
mixed  infections  occurring  in  man,  when  pyogenic  cocci  are  injected  at 
the  same  time. 

Literature. — E.  Frdnkel.  Ueber  Gasphlegmone,  Schaumorgane  und  deren  Erreger. 
Zeitschr.  f.  Hygiene,  Bd.  40,  1902,  p.  73.— Passini.  Stud,  iiber  faulniserregende 
anaerobe  Bakterien  des  menschl.  Darmes  und  ihre  Bedeutung.  Zeitschr.  f.  Hygiene, 
Bd.  49,  1905,  p.  135. — Stolz.  Die  Gasphlegmone  des  Menschen.  Beitr.  z.  klin.  Chir., 
Bd.  33,  1902,  p.  72. 

Bacillus  of  Malignant  (Edema. — The  bacillus  of  malignant  oedema 
is  the  cause  of  malignant  oedema  in  man,  and  is  therefore  one  of  the 
most  important  of  the  group  of  bacilli  producing  a  spreading  inflam- 
matory oedema  associated  with  emphj^sema,  and  eventually  ending  in 
gangrene. 

It  is  narrower  than  the  anthrax  bacillus  and  has  rounded  ends.  In 
the  tissues  and  in  cultures  it  gro^^s  out  into  long  filaments,  which  may 
be  uniform  throughout  or  segmented  at  irregular  intervals.  Under 
suitable  conditions  they  form  long  spores  which  lie  near  the  center  of 
the  rods. 

The  bacillus  is  a  strong  ana?robe,  and  can  therefore  onlj'  be  grown 
when  air  is  excluded,  but  it  can  be  grown  without  difficulty  upon  ordi- 
nary culture  media,  gelatin  being  liquefied  and  gas  formed.  Large 
amounts  of  foul-smelling  gases  are  formed  when  the  bacilli  are  grown 
in  culture  media  containing  grape-sugar,  and  in  blood  serum,  for  the 
bacilli  belong  to  the  bacteria  which  decompose  albumins  with  the  devel- 
opment of  foul-smelling  gases  (Jensen).  The  bacilli,  the  spores,  and 
the  flagella  may  be  stained  by  the  methods  ordinarily  employed.  The 
bacilli  lose  their  color  in  (Jram's  method,  in  this  way  diff'ering  from  those 
of  anthrax. 

The  bacillus  of  malignant  oedema  is  very  widely  distributed,  being 
frequently  found  in  decomposing  fluids,  in  iiii])iir('  water,  in  the  upper 
layers  of  the  earth,  down  to  1  m.  in  the  dust,  in  the  intestinal  canal  and 
fa'ces  of  herbivorous  animals,  and  therefore  it  occurs  frequently  in  milk 
and  farm  produce.  It  has  been  demonstrated  upon  the  human  nmcous 
membranes   (Jensen). 

It  thrives  especially  wi'U  u])<)n  necrotic  tissues  and  in  deep  wounds 
with  pockets  and  recesses.  It  produces,  following  wound  infections  in 
horses  or  puerperal  infections  in  cows,  an  acute  febrile,  frequently 
fatal,  disease  characterized  by  an  extensive  serolia,*morrhagic  and  em- 
physematous o'dema. 


PUTREFACTIVE    INFECTIONS  299 

It  was  first  described  in  man  by  Briejier  and  Ehrlieh  (1882)  in  two 
cases  of  rapidly  progressive  cedematous  inflammation,  which  soon  ended 
fatally.  Feser  and  Pasteur  had  fonnd  the  bacillus  as  early  as  1876  in 
inflammations  Avhieh  they  had  produced  in  experimental  animals  by  the 
injection  of  decomposing  materials.  The  name  was  given  it  by  Koch, 
who  first  described  it  accurately. 

The  toxins,  which  are  negatively  chemotactic,  are  formed  in  small 
amounts  only.  As  the  toxins  are  negatively  chemotactic,  there  is  no 
emigration  of  leucocytes.  They  irritate  the  blood  vessels  and  nerves, 
causing  an  accumulation  of  a  serous  exudate. 

Literature. — Jensen.  Malignes  Oedem.  In  Kolle-Wassermanus  Ilandb.  d.  path. 
Mikroorg.,  Bd.  II,  1903,  p.  61',). 

Conditions  Essential  for  Putrefaction. — Two  conditions  are  essential 
to  the  development  of  putrefactive  changes:  (1)  The  presence  of  degen- 
erated or  necrotic  tissue.  (2)  Deep  recesses  or  pockets  in  a  wound  to 
which  the  air  does  not  have  free  access.  Apparently  syml)iosis  of  the 
putrefactive  bacteria  with  a  number  of  difi:erent  anan'obic  saprophytes 
plays  an  important  role  in  the  putrefactive  infections.  The  virulence 
of  putrefactive  bacteria  is  increased  by  streptococci,  and  the  putrefactive 
infections  are  more  frequently  mixed  infections  with  the  proteus  and 
colon  bacilli  and  streptococci  than  monoinfections.  Tetanus  bacilli  find 
conditions  favorable  for  development  in  wounds  in  which  there  are 
putrefactive  changes. 

Ectog-enous  Putrefactive  Infections. — There  are  two  reasons  why 
ectogenous  putrefactive  infections  are  rare,  notwithstanding  the  fact 
that  the  putrefactive  bacteria  are  so  widely  distributed,  and  that  sur- 
geons are  often  compelled  to  work  under  adverse  conditions,  especially 
in  war:  (1)  Putrefactive  bacteria  cannot  develop  in  superficial  acci- 
dental wounds  because  of  the  free  access  of  air;  (2)  in  the  treatment 
of  Avounds  as  carried  out  at  the  present  time  all  the  infected  recesses  are 
opened  and  drained,  and  the  dressings  are  so  applied  as  to  permit  of 
a  free  access  of  air;  and  as  a  result  putrefactive  infections  rarely  de- 
velop even  in  compound  fractures  or  machine  injuries,  which  were  in- 
fected at  the  time  of  the  accident  or  later  by  meddlesome  laymen.  Se- 
vere ectogenous  putrefactive  infections  occur  almost  only  in  injui-ies 
such  as  those  described  above  in  which  the  surgeon  is  called  late.  Puti-e- 
f active  puerperal  infections  should  be  regarded  as  of  ectogenous  origin, 
as  in  the  majority  of  cases  the  causes  of  the  infection  (colon  and  proteus 
bacilli)  are  carried  into  the  vagina  when  proper  aseptic  precautions  are 
not  taken  in  making  an  examination. 

Endogenous  Putrefactive  Infections.— Endogenous  putrefactive  in- 
fections developing  from  the  mucous  membranes  of  the  mouth,  intes- 


300  WOUND   INFECTIONS  PRODUCED   BY   BACTERIA 

tines,  bladder,  and  urethra  are  more  frequent  than  the  ectogenous. 
These  infections  occurring  in  the  mouth  are  associated  with  a  number 
of  lesions  Avhich  lead  to  the  formation  of  circumscribed  and  superficial 
areas  of  gangrene,  occurring  as  secondary  infections  in  stomatitis  ulcer- 
osa, angina  gangrenosa,  and  pharyngeal  diphtheria.  They  follow  fre- 
quently the  laceration  of  the  tongue,  produced  by  shooting  into  the 
mouth  in  attempted  suicide.  The  putrefactive  phlegmon  which  then 
develops  in  the  floor  of  the  mouth  spreads  along  the  layers  of  the  cervi- 
cal fascia  and  may  cause  an  axlema  of  the  glottis,  which  may  prove  fatal 
unless  proper  treatment  is  instituted.  A  retropharyngeal  phlegmon  fol- 
lows an  injury  of  the  pharynx.  A  phlegmon  about  the  oesophagus  de- 
velops when  a  foreign  bcdy  which  has  become  arrested  ulcerates  through 
the  oesophagus,  when  an  a^sciphageal  carcinoma  ruptures  externally, 
and  after  injuries  produced  by  the  a\sophagoscope.  Phlegmons  devel- 
oping from  either  the  pharynx  or  oesophagus  may  extend  between 
the  layers  of  the  cervical  fascia  to  the  mediastinum  and  cause  death. 
Periostitis  alveolaris  leading  to  the  formation  of  a  foul-smelling,  usually 
benign,  abscess  frecpiently  develops  from  a  periodontitis  produced  by  a 
carious  tooth  with  a  decomposing  pulp.  Very  rarely,  however,  does  a 
fatal  general  infection  follow  the  latter  lesion.  If  a  carcinoma  of  the 
tongue  or  larynx  becomes  infected  with  putrefactive  bacteria,  they  may 
be  cai'ried  to  the  lungs,  and  an  inflammation,  which  is  rapidly  followed 
by  gangrene,  then  develops.  In  gunshot  wounds  of  the  lungs  gangrenous 
foci,  putrefactive  pleurisy,  and  secondary  infection  of  a  hfemothorax 
may  be  produced  either  by  putrefactive  bacteria  which  have  been  aspi- 
rated or  by  those  which  have  been  carried  into  the  wound  upon  a  piece 
of  clothing.  P}il(>gm<)ns  should  also  be  mentioned  which  develop  about 
the  trachea  secondary  to  carcinomatous,  tuberculous,  and  syphilitic  le- 
sions of  the  larynx. 

Putrefactive  Peritonitis  following  Perforation  and  Rupture  of  the 
Intestines. — Pei-foration  of  the  intestines  is  followed  l)y  an  acute,  ])ro- 
gressive,  putrefactive  peritonitis,  accompanied  by  a  fatal  general  infec- 
tion Avhich  is  usually  toxic  in  character,  for  in  sudden  perforations  there 
is  no  agglutination  of  the  intestinal  loops,  and  the  inflanunatory  process 
is  not  walled  off;  therefore  the  intestinal  ferments  and  bacterial  toxins 
which  destroy  the  protecting  endotheliiun  and  the  bacteria  (especially 
the  proteus  and  colon  bacilli  associated  with  different  pyogenic  cocci) 
are  poured  diccclly  info  flie  free  pcrifonejil  cavity. 

Periprocteal  Abscesses  and  Infections  following  Extravasation  of 
Urine. — A  beuign  circvuuscribed  phlegmon  (the  periprocteal  abscess) 
fi'oMi  wliicli  fistulii'  ill  auo  develop  fre(|ueutly  foruis  about  the  rectum 
I'nllowitiii  injuries  by  inspissated  fjecal  masses.  Injuries  of  the  bladder 
and  urellua  are  fre(juently  followed  by  severe  phlegmons  when  the  ex- 


PUTREFACTIVE   INFECTIONS  301 

travasated  nrine  contains  putrefactive  bacteria.  IMild  endojienons  putre- 
factive infections  are  occasionally  seen  after  operations  about  the  rectum, 
and  in  operations  ui)on  the  intestines  when  the  fa'ces  are  permitted  to 
flow  over  the  wound.  Similar  infectious  occur  in  plastic  o])eratioiis  upon 
the  lips  and  cheeks  when  a  poorly  nourished  tlap  dies  and  becomes  gan- 
grenous following  infection  with  bacteria   from  the   mouth  cavity. 

Symptoms  of  Putrefactive  Infections. — AVhen  putrefactive  inflamma- 
tion develops  in  a  wound  the  temperature  either  rises  abruptly  with  a 
chill  or  steadily,  and  the  appearance  of  the  wound  becomes  very  char- 
acteristic within  twenty-four  hcmrs.  A  foul,  ri>pelleiit  odor  arises  from 
the  dry  wound  surfaces.  The  loosely  attached  shreds  of  tissiie  and  the 
skin  edges  for  a  varying  distance  have  a  bluish  or  black  color.  Twenty- 
four  hours  later  small  amounts  of  a  brownish  or  greenish  ichorous  dis- 
charge are  poured  out  from  the  deepest  recesses  of  the  wound,  while  the 
inflammatory  redness  and  swelling,  accompanied  b}^  an  increasing  pain, 
extend  into  the  surrounding  tissues.  Soon  the  Avound  surfaces  become 
discolored  and  moist,  and  the  large  shreds  of  necrotic  tissue  become 
liquefied  or  are  cast  off.  When  pressure  is  made  upon  the  surrounding 
tissues,  gas  bubbles  appear  in  the  ichorous  discharge.  If  the  iuHam- 
matory  process  subsides  the  inflammatory  swelling  and  ichorous  discharge 
gradually  disapl^ear,  healthy  granulation  tissue  develops  around  the  gan- 
grenous area  and  healing  occurs.  In  the  wcrst  cases  a  high  continuous 
fever  persists  and  the  symptoms  of  general  infection,  which  correspond 
exactly  to  those  occurring  in  general  pyogenic  infections,  develop ;  death 
occurring  in  a  few  days,  frequently  at  the  end  of  the  first  day.  Fre- 
quently streptococci,  more  rarely  staphylococci  or  colon  bacilli,  are  found 
in  the  circulating  blood.  Even  the  proteus  vulgaris  has  been  found  in 
the  blood  in  these  cases  (Krogius).  In  most  cases,  however,  bacteria 
cannot  be  demonstrated  in  the  blood,  which  is  laden  with  toxic  nuite- 
rials  as  indicated  by  the  severe  changes  occurring  in  it.  If  metastases 
develop,  they  have  the  same  putrefactive  character  as  the  primary  focus. 

Putrefactive  Phlegmon. — If  the  putrefactive  inflammation  extends,  a 
phlegmon  forms  which  develops  more  rapidly,  and  is  accompanied  by 
severer  local  and  general  symptoms  than  the  most  malignant  strepto- 
coccic infections.  The  names  which  have  been  applied  to  putrefactive 
phlegmons  by  different  authors,  acute  suppurative  (edema  ending  in 
gangrene  (Pirogoft'),  progressive  gangrenous  emphysema,  emphysema- 
tous gangrene,  fulminating  gangrene  (Maissoneuve),  gangrenous  emphy- 
sema, gangrenous  phlegmon,  panphlegmon  gangra^nosa  (Fischer),  etc., 
describe  very  well  the  clinical  picture.  Often  within  twenty-four  hours 
an  entire  extremity  becomes  so  cedematous  and  i-ed  that  the  painful 
swollen  lymph  nodes  can  no  longer  be  palpafed,  and  the  red  streaks 
indicative   of  lymphangitis,  Avhich   is   rarely   absent,   can   no   longer  be 


302  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

seen.  The  inflaniinatory  exudate  is  so  great  that  the  circumference  of 
the  extremity  becomes  three  or  more  times  as  great  as  normal,  and  exerts 
so  much  pressure  that  the  circulation  is  interfered  with.  The  tense  skin 
becomes  pale  and  anaesthetic,  and  large  blebs  with  seroha^morrhagic  con- 
tents form;  bluish  discolored  areas  develop  and  become  transformed 
into  black  crusts,  which  are  cast  off  as  the  gangrene  extends.  Fluc- 
tuation cannot  be  elicited  anywhere  in  the  enormously  swollen  extremity, 
but  when  the  tissues  are  palpated  an  emphysematous  crackling,  which 
is  characteristic  of  gas  in  the  tissues,  may  be  elicited.  The  fingers  or  toes 
are  of  a  pale  or  bluish  color  and  feel  cold.  When  these  infections  develop 
from  wounds  they  rarely  remain  confined  to  the  subcutaneous  tissues, 
but  extend  to  the  muscles  and  periosteum,  and  when  a  compoiuid  frac- 
ture becomes  infected,  the  bone  marrow  is  transformed  into  a  decom- 
posing, putrefying  mass  (putrefactive  osteomyelitis).  Putrefactive 
arthritis  is  accompanied  by  great  destruction,  the  capsule  becomes  necro- 
tic, the  cartilages  are  separated  and  destroyed. 

Appearance  of  Tissues  when  Incised. — AVhen  incisions  are  made  the 
frightful  results  of  these  infections  are  revealed.  The  incision  passes 
through  an  o'dematous  or  gangrenous  cutis  into  an  cedematous,  grayish- 
green  subcutaneous  tissue  from  which  a  sanious  discharge  containing  gas 
bubbles  and  shreds  of  fat  and  fascia  pour  out.  The  intermuscular  con- 
nective tissues  and  nuiscles  are  in  the  same  condition.  Everywhere  a 
gelatinous,  discolored  network  of  tissue  is  found  from  which  an  ichorous 
discharge  and  gas  bubbles  can  be  expressed.  The  periosteum  is  raised 
from  the  bone  and  separated  into  gangrenous  shreds,  while  from  the 
bone  marrow  decomposing  matter  is  discharged  from  the  seat  of  frac- 
ture or  through  large  canals  in  the  bone.  The  subcutaneous  and  deeper 
veins  become  thrombosed,  the  thrombi  frequently  undergoing  septic  sof- 
tening; the  walls  of  the  larger  arteries  have  a  grayish  color  and  are 
about  to  ]'U!)fure  (gangrenous  arteritis).  Fatal  haemorrhage  may  fol- 
low the  erdsion  of  an  artciy  by  the  gangrenous  process. 

Putrefactive  Phlegmons  following  Urinary  Extravasation,  and  the 
Escape  of  Faecal  Matter. — Putrefactive  phlegmons  develop  in  the  scrotum, 
penis,  and  perineum  following  urinary  extravasation.  The  urine  is 
poured  out  into  the  tissues  after  injuries  or  inflammatory  processes  which 
destroy  the  integrity  of  the  urinary  passages,  such  as  fractures  of  the  pel- 
vic bones,  periurethj'itis  following  urethral  strictures,  and  injuries  pro- 
duced while  introducing  catheters.  A  rapidly  progressive  swelling  and 
r<(|iiess,  accompanied  by  severe  pain  and  fever,  indicate  the  beginning 
of  the  inflammation  M'hich  leads  to  extensive  gangrene  of  the  nniscles, 
fascia,  and  skin,  if  death  from  a  general  toxic  infection  does  not  occur 
bel'oi'e  gaiigreni  lias  lime  to  develop.  Tlie  greater'the  number  of  bac- 
teria in   till'   urine  sueli   ;is   occur  in   cystitis  following  hypertro])liy  of 


PUTREFACTIVE    INFECTIONS  303 

the  prostate  and   uivtliial  slficture.  the  iinn'e  i-apid  and  sevei'e  tlie  iii- 
flaiiiiimtion  will  be. 

A  similar  but  less  rriyliti'ul  clinical  ])ictiu'e,  as  in  this  ease  pressure 
is  not  exerted  as  when  urine  is  extravasated,  is  produced  by  the  discharge 
of  fa?eal  matter  into  the  tissues,  following,  for  example,  gangrene  of  a 
strangulated  intestinal  loop  in  a  hernia  (fascal  phlegmon  and  abscess). 
Necrotic  and  dying  tissue  affords  the  best  cnlture  media  for  pntref active 
bacteria,  and  the  development  of  putrefactive  inflammation  following 
the  various  forms  of  necrosis  is  not  at  all  rare  unless  prophylactic  meas- 
ures are  instituted  early.  Bed  sores  about  the  sacrum  and  coccyx  easily 
become  infected  from  fgecal  matter.  Gangrene,  and  in  neglected  cases 
putrefactive  phlegmons  and  general  infections,  may  then  develop.  A 
similar  infection  followed  by  similar  results  not  infrequently  develops  in 
tuberculous  fistula*  about  the  perineum  treated  by  quacks. 

Putrefaction  in  Senile  and  Arteriosclerotic  Gangrene. — Senile  gan- 
grene and  arteriosclerotic  gangrene  of  the  fingers  and  toes  readily  pass 
from  the  condition  of  dry  necrosis  or  mummification  into  that  of  a  moist 
putrefactive  gangrene,  which  aifords  opportunities  for  the  development 
of  phlegmons.  A  gangrene  due  to  freezing,  embolism  of  the  arteries  of 
the  extremities,  nervous  lesions,  and  carbolic-acid  ccmipresses  may  also 
give  rise  to  putrefactive  phlegmons.  Pyogenic  and  putrefactive  infec- 
tions develop  most  rapidly  in  diabetic  gangrene.  The  resistance  of  the 
tissues  is  so  reduced  in  diabetes  that  lymphangitis  and  phlegmons  develop 
inniiediately  after  infection  with  putrefactive  bacteria. 

Treatment. — Prophylaxis  is  the  most  essential  factor  in  the  treatment 
of  putrefactive  infections.  The  detached  and  contused  tissues  should 
be  removed  from  lacerated  wounds,  the  edges  of  the  wound  should  be 
trinnned  off,  then  the  wound  should  be  loosely  tamponed  and  should  be 
di-ained  and  treated  by  the  open  method.  Secondary  infection  should 
be  prevented  by  sterilizing  the  surrounding  area  and  avoiding  any  use- 
less examinations  or  manipulations.  If  gangrene  has  already  developed, 
a  dry  aseptic  dressing  should  be  applied.  Putrefactive  processes  rap- 
idly develop,  especially  in  diabetic  patients,  when  moist  dressings  are 
used.  If  the  inflannnation  has  already  developed,  the  infected  tissues 
should  be  freely  exposed  by  opening  the  recesses  and  pockets  of  the 
wound  and  by  incising  fi-eely  the  phlegmon  or  abscess.  In  the  beginning 
a  tampon  of  dry  aseptic  gauze  should  be  used.  Iodoform  gauze  is  contra- 
indicated,  as  the  iodoform  is  ((uickly  decomposed  in  putrefactive  proc- 
esses and  may  give  rise  to  severe  toxic  synqitoms.  AVhen  an  extensive 
gangrene  has  developed  in  the  wound,  or  there  is  a  superficial  gangrene 
of  the  skin,  compresses  of  a  three  pi>r  cent  solution  of  acetate  of  alumi- 
num, of  boric  acid  or  hydrogen  p(>i-oxi(1  solution  may  be  used  to  hasten 
the  separation  of  the  dead  tissu(\     When  severe^  general  symptoms  de- 


304  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

velop  amputation  of  the  inflamed  extremity  should  l)e  eonsidered,  al- 
though only  in  rare  cases  is  one  able  to  prevent  the  dangers  of  general 
infection  even  by  this  radical  procedure. 

(b)     ALLIED    PROCESSES 

Gas  Phlegmon. — The  gas  phlegmon  may  be  called  a  variety  of  gan- 
grenous phlegmon,  which  is  characterized  by  the  formation  of  large 
amounts  of  gas.  The  skin  is  raised  from  the  subjacent  tissue  by  large 
accumulations  of  gas,  resembling  an  air  cushion ;  while  after  death  there 
is  a  rapid,  progressive  formation  of  gas  in  the  viscera  (so-called  foam 
organs).  The  more  pronounced  the  gangrene,  the  less  marked  are  the 
inflammatory  symptoms. 

The  bacillus  aerogenes  capsulatus  and  allied  ana?robic  bacteria 
(butyric  acid  bacilli)  appear  to  be  the  most  important  causes  of 
gas  phlegmon  (Welch  and  Flexner,  Muscatello,  Hitzmann  and  Lin- 
denthal,  Stolz,  Koprac).  The  bacillus  aerogenes  capsulatus  was  found 
by  Lenhartz  in  the  blood  during  life  in  a  puerperal  infection  which 
ended  fatally. 

The  proteus  bacillus  (Graszberger,  Widal,  and  Nobecourt)  and  the 
bacterium  eoli  commune  (Chiari,  Klemm,  Bunge,  Tavel,  and  others)  are 
occasionally  found  in  gas  phlegmons. 

Mixed  infections  with  pyogenic  bacteria  are  also  frequent. 

Malignant  (Edema. — Malignant  oedema  is  a  term  often  applied  to 
acute  suppurative  and  putrefactive  phlegmons;  it  should  be  used,  how- 
ever, only  to  designate  those  rare,  rapidly  progressive  phlegmons  accom- 
panied by  gas  formation  and  gangrene  of  the  skin  and  subjacent  tissues, 
which  are  caused  by  the  bacillus  of  malignant  oedema  alone  or  associated 
with  other  bacteria.  Even  after  a  bacteriological  examination  it  is  fre- 
quently impossible  to  make  a  positive  diagnosis  because  of  the  similarity 
of  the  bacteria  ((Jhon  and  Sachs)  found  in  these  analogous  inflammatory 
processes. 

The  exudate  before  gangrene  begins  is  serous  in  character  and  con- 
tains but  few  cells.  This  is  due  to  the  fact  that  the  bacterial  toxins  exert 
a  negative  chemotaxis ;  the  same  occurring  in  gas  phlegmons,  in  which 
there  is  no  secondary  infection  with  pyogenic  bacteria. 

The  treatment  of  gas  phlegmons  and  of  malignant  oedema  is  the  same 
as  that  of  putrefactive  phlegmons. 

LiTERATUitE. — Alhrecht.  Ueber  Infektionen  mit  gasbildenden  Bakt.  Arch.  f. 
klin.  Chir.,  Bd.  67,  1902,  p.  514. — E.  v.  Bergmnnn.  Zur  Lehre  von  dor  putriden  In- 
toxikation.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  1,  1872,  p.  :i7',i.—Bricger.  Untersuchungen 
iil)cr  Ptomaine,  Berlin,  188.'j-f). — Brunner.  Wundinfektion'  und  Wundbehandlung. 
Frauenfeld,    18i*8. — E.    Eriinkd.     Ueber    Gasphlegmonen,    Schaumorgane  und  deren 


PUTREFACTIVE   INFECTIONS  305 

Erreger.  Zeitschr.  f.  Hygiene,  Bd.  40,  1902,  p.  73. — Ghon  und  Sachs.  Beitriigezur 
Kenntnis  der  anaeroben  Bakterien  des  Menschen.  Zur  Aetiologie  des  Gasbrandes. 
Zentralbl.  f.  Bakt.,  1903,  Bd.  34,  Orig.,p.  289  and  Bd.  36,  Orig.,  1904,  p.  178.— Kamen. 
Zur  Aetiologie  der  Gasphleginone,  Ebenda,  Bd.  35,  1904,  p.  554. — Koprac.  Ein  Beitrag 
zur  weiteren  Differenzierung  der  Gangrene  foudroyante.  Arch.  f.  klin.  Chir.,  Bd.  72, 
1904,  p.  111. — Lenhartz.  Die  septischen  Erkrankungen.  Wien,  1903. — Panum.  Das 
putride  Gift,  etc.  Virchows  Arch.,  Bd.  60,  1874,  p.  301. — Piroijoff.  Grundziige  der 
allgemeinen  Kriegschirurgie.  Leipzig,  1864. — Sandler.  Ueber  Gasgangran  u.  Schauni- 
organe.  Mitteilung  u.  Sammelreferat.  Zentralbl.  f.  allgem.  Path.,  1902,  p.  471. — 
Stolz.—Bie  Gasphleginone  d.  Menschen.  Beitr.  z.  klin.  Chir.,  Bd.  33,  1902,  p.  72.— 
Westenhoeffer.  Weit.  Beitrage  z.  Frage  der  Schaumorgane  u.  der  Gangrene  foudr. 
Virchows  Archiv,  Bd.  170,  1902. 

Noma  ^  {Water  Cancer,  Gangrene  of  the  Cheek). — Noma  is  closely 
allied  to  those  putrefactive  infections  in  which  gangrene  predominates. 
It  involves  most  frequently  the  cheeks,  more  rarely  the  gums,  palate, 
and  lips.     Similar  infections  occur  about  the  anus  and  vulva. 

Etiology. — The  disease  attacks  almost  exclusively  weak  and  ema- 
ciated young  children  from  two  to  twelve  years  of  age,  living  in  squalid, 
over-populated  districts  in  cities;  much  more  rarely  adults.  Measles 
and  typhoid  fever,  syphilis,  mercurial  stomatitis,  diphtheria,  dysentery, 
different  forms  of  ulcerative  stomatitis,  malaria,  poor  hygienic  condi- 
tions are  predisposing  and  accessory  causes  which  reduce  the  local  and 
general  resistance  and  prepare  the  tissues  for  the  development  of  bac- 
teria. Noma  is  apparently  a  bacterial  infection,  but  a  specific  organism 
has  not  as  yet  been  demonstrated. 

As  a  rule,  only  isolated  cases  occur,  and  the  possibility  of  direct 
transference  from  one  patient  to  another  can  be  excluded.  Wherever  a 
number  of  cases  have  developed  in  the  same  hospital  or  district,  there 
has  been  a  preceding  epidemic  of  measles. 

Bacteria  and  Fungi  found  in  Noma. — A  number  of  different  bac- 
teria and  fungi  have  been  found  in  noma.  This  is  not  to  be  wondered 
at  when  one  considers  the  great  variety  and  number  of  bacteria  normally 
present  in  the  mouth  and  found  in  putrefactive  processes.  Perthes  dem- 
onstrated microscopically  a  streptothrix  in  the  margin  of  the  gangrenous 
area  which  sends  out  its  terminal  processes  in  the  form  of  spirilla  into 
the  adjacent  healthy  tissues.  He  was  unable  to  produce  the  disease  in 
animals  with  this  streptothrix  or  to  groAV  it  in  pure  cultures.  Freymuth 
and  Petruschky  found  the  diphtheria  bacillus  in  two  eases  of  noma  ob- 
served by  them.  It  is  doubtful,  however,  whether  the  diphtheria  bacillus 
should  be  regarded  as  the  cause  of  these  cases  of  noma,  as  they  are  found 
in  the  mouth  of  healthy  individuals.  It  is  a  question  whether  noma  is 
caused  by  any  single  variety  of  bactei-ia,  or  wlu'tlier  it  is  caused  by  a 
number  of  different  varieties  (Kolle  and  Hetsch). 

1  From  the  Greek  vtneaeai — to  destroy. 


306 


WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 


Clinical  Course. — The  specific  process  begins  in  an  abrasion  or  an  in- 
flamed area  (ulcerative  or  mercurial  stomatitis)  in  the  mucous  mem- 
brane of  the  cheek,  near  the 
angle  of  the  mouth,  occasion- 
ally in  the  mucous  membrane 
of  the  palate,  lips,  or  gums. 
Gangrene  gradually  develops 
from  a  vesicle  Avitli  cloudy  con- 
tents or  a  superficial  ulcer,  and 
extends  both  superficially  and 
deeply.  As  the  gangrene  spreads 
the  surrounding  tissues  become 
inflamed,  indurated,  and  hard. 
A  high  fever  develops  and  per- 
sists; the  severity  of  the 
disease  is  indicated  by  the 
height  of  the  fever  and 
the  mental  disturbances. 
A  swellinef   of    the   cheek      ■ 


Fig.  127. — Noma  in  a  Chinaman  Sixteen  Years 
OF  Age.  (After  photographs  and  communi- 
cation of  Professor  Perthes.)  Tenth  day  of 
the  disease.  The  dark  area  in  cheek  is  the 
point  at  which  perforation  is  about  to  oc- 
cur. 


I'^ifi.  128.  —  PicTi'iir,  Taken  on  Sixikknth  1).\y  of 
THE  Disease  Aktioii  ('auterization.  DeaMi  on 
twenty-.second  day,  tlio  disca.se  having  extend- 
ed to  tlie  pharynx  and  soft  palate. 


which  is  not  very  painful  de- 
velops, and  soon  there  ap- 
pears upon  the  pallid  skin  a 
bluish-black  discoloration  cor- 
responding approximately  to 
the  area  of  mucous  membrane 
which  is  infiltrated.  This 
bhiish-black  discoloration  of 
the  tissues  is  characteristic  of 
noma. 

As  the  disease  progresses 
Ihc  iufhiiiiinatory  reaction  may 
beeomc  marked  and  the  entire 
face  niid  the  side  of  th<;  neck 
becomes  swollen,  but  the  gan- 
grenous i)ro('ess  does  not  sub- 


PUTREFACTIVE    INFECTIONS 


307 


side.  Within  the  first  week  the  dark,  gangrenous  tissues  sk)iigh  out; 
the  process  extends  and  destroys  the  cheek,  the  mucous  membrane  cover- 
ing the  upper  and  lower  jaws;  the  teeth  become  loosened  and  drop  out, 
and  the  surfaces  of  the  maxilla  and  mandible  become  exposed.  In  the 
malignant  cases  the  gangrene  extends  to  the  nose,  the  tongue,  the  phar- 
ynx, the  palate,  the  lips,  and  the  other  cheek.  The  amount  of  saliva 
is  increased  and  a  foul-smelling  discharge  is  poured  into  the  mouth, 
which  may  be  swallowed  and  aspirated,  causing  gastrointestinal  dis- 
turbances, bronchopneumonia,  and  gangrene  of  the  lung. 

Prognosis. — Death,  which  frequently  occurs  at  the  end  of  the  first 
week,  ends  the  frightful  suffering  in  seventy-five  per  cent  of  the  cases 
It  is  due  to  paralysis  of  the 
heart,  resulting  from  a  general 
toxic  infection,  exhaustion,  or 
pneumonia.  In  rare  cases  the 
gangrene  subsides  after  the  ne- 
crotic tissues  have  sloughed  out, 
and  then  it  does  not  extend  into 
the  surrounding  inflamed  tis- 
sues ;  healthy  granulations  form, 
the  necrotic  soft  tissues  and 
bone  are  separated  and  cast  ofif, 
and  healing  occurs.  Large  de- 
fects of  the  cheek,  lip,  and  nose, 
with  cicatricial  lockjaw  and  ec- 
tropion, remain  after  healing. 

Treatment. — The  treatment 
consists  of  destruction  of  the 
gangrenous  tissue  with  the  Pa- 
(luelin  cautery.  The  entire  thick- 
ness of  the  cheek  in  which  the 
gangrene  develops  should  be 
cauterized,  and  even  the  healthy 
tissue   immediately   adjacent  to 

it.  Trendelenburg  recommends  splitting  the  eheok  in  order  to  expose 
more  thoroughly  the  diseased  area.  Attempts  have  been  made  to  prevent 
the  putrefactive  decomposition  of  the  gangrenous  tissue  by  the  use  of 
caustics  (zinc  chlorid,  acetic  acid)  and  to  control  the  inflammation  by 
using  a  five  per  cent  solution  of  hydrogen  peroxid  as  a  mouth  wash 
frecjuently.  If  treatment  is  instituted  early,  procedures  which  are  not 
mutilating  may  be  successful.  Every  effort  should  be  made  to  improve 
the  general  condition  of  the  patient. 

It  may  be  necessary  to  perform  plastic  operations  to  close  the  defects, 


Fig.  129. — Deformity  Following  a  Noma  of 
THE  F.\CE,  Which  Healed. 


308  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

and  to  remove  the  masses  of  cicatricial  tissue  to  cure  the  cicatricial  lock- 
jaw. 

Literature. — v.  Bergmann.  Verletzungen  und  Erkrankungen  der  Mundhohle 
Handb.  d.  prakt.  Chir.,  2d  Edition. — Kolle  und  Hetsch.  Noma.  In  Kolle-Wassermanns 
Handb.  d.  pathog.  Mikroorg.,  Bd.  3,  1903,  p.  904. — Krahn.  Ein  Beitrag  zur  Aetiologie 
der  Noma.  Mitteil.  a.  d.  Grenzgeb.,  Bd.  6. — Perthes.  Ueber  Noma  und  ihren  Erreger. 
Chir.-Kongr.  Verhandl.,  1899,  II,  p.  63.^ — v.  Ranke.  Zur  patholog.  Anatomie  des 
nomatosen  Brandes.     Miinch.  med.  Wochenschr.,  1903,  p.  13. 

Hospital  Gangrene  {^yo\(V(^  Pliagcdmia). — By  hospital  frangrene  is 
understood  a  wound  infection  resulting  in  an  acute  progressive  necrosis 
of  the  tissues  with  putrefactive  decomposition  of  the  same.  The  name 
cf  hospital  gangrene  has  been  given  to  this  form  of  infection,  as  in  pre- 
antiseptic  times  it  frequently  occurred  in  epidemic  form  in  civil  and 
military  hospitals.  The  infection  was  transferred  from  wound  to  wound 
by  the  lint  and  sponges  (the  materials  used  for  dressing  wounds  in  ear- 
lier times),  the  instruments,  and  the  fingers  of  the  operator  or  his  assist- 
ants. It  attacked  recent  and  old,  large  and  small  wounds,  and  pursued  a 
rapid  and  severe  course,  which  often  ended  fatally. 

At  the  present  time  the  surgeon  occasionally  sees  a  case  of  the  milder 
form  of  hospital  gangrene,  which  develops  most  frequently  about  the 
anus  or  the  external  genitalia.  Operation-  and  accidental-wounds  are 
but  rarely  attacked  by  this  form  of  infection. 

Etiology. — Hospital  gangrene  is  apparently  of  bacterial  origin,  but 
no  specific  bacterium  has  yet  been  found.  Vincent  and  Matzenauer  have 
demonstrated  a  bacillus  in  a  number  of  cases,  but  have  been  unable  to 
grow  it  in  pure  cultures.    Nasse  found  in  one  case  an  amoeboid  organism. 

If  one  reads  the  descriptions  of  hospital  gangrene  given  by  the  older 
authors,  one  cannot  help  thinking  that  a  number  of  different  infections 
— putrefactive  gangrene  and  phlegmon,  perhaps  even  gas  phlegmon, 
and  infections  with  the  diphtheria  bacillus  (wound  diphtheria) — were 
grouped  under  this  term. 

Cluiical  Course  and  Forms. — Depending  upon  the  course,  authors 
have  differentiated  a  superficial  and  a  deep  form  of  hospital  gangrene 
(Phageda'ua  superficialis  et  profunda,  von  Pitha,  Kihiig)  ;  upon  the 
gross  api)earanee  an  ulcerative  and  a  pulpy  gangrene  (Delpech). 

The  symptoms  begin  after  an  incubation  ])(M-iod  of  from  two  to  three 
days  with  fever,  i)ain,  and  changes  in  the  appearance  of  the  wound.  In 
the  ulcerative  foi-ni  which  attacks  especiall.y  granulating  wounds,  the 
wound  surface  becomes  mottled  with  yellowish-brown  areas,  and  small 
baMiioi-rhages  occur  within  the  granulations.  If  the  changes  are  mild  and 
not  progressive,  one  speaks  of  a  diphtheritic  form  of  hos])ital  gangrene. 
In  the  ulcerative  form  the  gangrene  extends  rapidly  over  the  entire 
wound,  transform iiig  llie  tissues  into  a  discolored,   foul-snielling  mass- 


PUTREFACTIVE   IXFEt'TIOXS  309 

"When  the  gangrenous  tissues  are  cast  off,  uleei-s  M'ith  sharply  cut 
edges  remain  which  rapidlj'  coalesce.  While  the  ha;inorrhagic  mottled 
floor  of  the  ulcer  becomes  gangrenous,  the  sharply  cut,  irregular  borders 
of  the  ulcer,  surrounded  by  painful,  inflamed,  and  infiltrated  skin,  ex- 
tend. The  changes  characteristic  of  the  pulpy  form  of  gangrene  may 
develop  in  the  floor  of  the  ulcer.  The  floor  of  the  wound  then  becomes 
dry  and  covered  with  a  thick,  dirty,  fibrinous  membrane,  which  may  be 
removed  in  shreds,  leaving  bleeding  surfaces.  After  a  short  time  an 
ichorous  secretion  is  poured  out,  and  the  surface  of  the  wound,  as  the 
result  of  putrefactive  changes  and  the  development  of  gas  within  the 
tissues,  becomes  transformed  into  a  grayish  black  or  yellowish  gray, 
firmly  attached,  semifluid  mass  (so-called  pulp),  which  has  been  com- 
pared to  decomposing  brain  matter.  These  changes,  which  may  fre- 
quently be  associated  with  considerable  parenchymatous  hemorrhage 
(hiemorrhagic  form),  may  develop  in  a  single  night  in  large,  recent 
operation- wounds  (for  example,  after  an  amputation). 

If  the  process  remains  superficial,  the  surface  of  the  wound  may 
gradually  become  clean,  and  covered  M'ith  healthy  granulation  tissue, 
but  the  infection  may  recur  at  almost  any  time  until  healing  is  complete. 

In  the  more  malignant  forms,  the  process,  which  resembles  closely  a 
putrid  phlegmon,  extends  deeply,  involving  the  loose  subcutaneous  and 
intermuscular  tissues  and  the  connective  tissues  of  the  vascular  sheaths. 
If  the  resistant  fascia  are  destroyed,  large  pieces  of  decomposing  muscle 
are  extruded.  If  the  process  still  extends  the  periosteum  is  destroyed  and 
the  superficial  layers  of  the  bone  become  necrotic,  the  walls  of  the  vessels 
ulcerate,  and  fatal  haBmorrhages  may  occur. 

Prognosis. — The  dry  forms  of  hospital  gangrene  may  cause  death 
within  two  days  by  rapid  extension,  accompanied  by  a  general  toxic 
infection.  The  mortality,  depending  upon  the  hygienic  conditions  and 
the  simultaneous  occurrence  of  other  diseases  (cholera,  typhoid  and  dys- 
entery), diffei'S.  It  varies,  according  to  the  statistics  compiled  l)y  dif- 
ferent authors,  from  6  to  80.6  per  cent  (Konig). 

Character  of  the  Fever. — The  fever  may  be  continuous  or  remittent, 
and  may  fall  abruptly  when  the  gangrene  subsides,  and  at'tei-  the  use 
of  the  actual  cautery  or  caustics.     In  rare  cases  it  begins  with  chills. 

The  general  symptoms  correspond  to  those  developing  in  general 
pyogenic  and  putrefactive  infections. 

Complkaiions. — Erysipelas,  metastatic  suppuration,  lymphangitis, 
lymphadenitis,  and  mixed  infections  with  pyogenic  bacteria  are  the  most 
frequent  complications. 

Diagnosis. — The  diagnosis  of  hospital  gangrene  under  conditions  ex- 
isting at  the  present  time  is  difficult.  So  few  cases  are  seen  that  one 
does  not  have  enough  clinical  experience  to  enable  him  to  recogni/.e  the 
21 


310  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

milder  forms,  and  the  severer  forms  of  hospital  gangrene  are  not  seen 
at  present.  It  is  scarcely  possible  to  differentiate  wound  dii)htlieria 
from  the  milder  forms  except  by  microscopic  examination  unless  the 
infection  develops  in  a  wonnd  npon  a  patient  already  suffering  with 
diphtheria. 

Treatment:  Prophylactic  and  Operative. — The  present  method  of 
treating  wounds,  and  improved  hygiene  in  both  civil  and  military  hos- 
pitals prevent  the  development  of  the  infection. 

Complete  isolation  of  patients  suffering  with  hospital  gangrene  is 
not  necessary.  They  should  be  separated  from  patients  recently  operated 
upon  with  clean  wounds,  but  may  be  kept  without  danger  in  wards  in 
which  patients  with  pyogenic  and  other  infections,  erysipelas,  etc.,  are 
isolated. 

The  early  and  energetic  use  of  caustics,  concentrated  zinc  ehlorid 
solution,  and  nitric  acid,  or  at  the  present  time  the  actual  cautery, 
plays  an  important  part  in  the  treatment.  Deep-lying  gangrenous  foci 
should  be  exposed  by  incisions  and  rendered  accessible. 

If  the  hsemorrhage  is  severe,  the  principal  artery  supplying  the  part 
should  be  ligated  at  some  distance  from  the  gangrenous  area,  in  healthy 
tissues  at  the  point  of  election. 

Amputation  is  indicated  when  the  general  symptoms  become  severe, 
and  may  be  the  only  measure  w^hich  will  save  the  life  of  the  patient. 

Literature. — Delpech.  Memoire  sur  la  complication  des  plaies  et  des  ulceres 
connues  sous  le  nom  de  pourriture  d'hopital.  Paris,  1815. — v.  Heine.  Der  Hospital- 
brand.  Handb.  d.  Chir.  v.  Pitha-Billroth,  Bd.  1,  2.  Abt.,  1869-74.— Komgr.  Ueber 
Hospitalbrand.  v.  Volkmanns  Sanmil.  klin.  Vortr.,  No.  40,  1872. — E.  Ktister.  Hos- 
pitalbrand.  In  Eulenburgs  Realenzyklopadie. — Mutzenauer.  Zur  Kenntnis  und 
Aetiologie  des  Hospitalbrandes.  Arch.  f.  Dermat.  u.  Syphil.,  Bd.  55,  1901,  p.  394. — 
Nasse.  Ueber  einen  Amobenbefund  bei  Leberabszessen,  Dysenterie  und  Nosokomial- 
gangriin.  Arch.  f.  klin.  Chir.,  Bd.  4.3,  1892,  p.  40. — Rosenbach.  Der  Hospitalbrand. 
Deutsche  Chirurgio.     Lief.  G,  1889. 


CHAPTER   VII 

SUPPLEMENT    TO    THE   TREATMENT    OF    ACUTE   INFLAMMATION 

The  recognition  of  the  fact  that  local  infections  (pyogenic  and  putre- 
factive) could  not  be  reached  by  drugs  administered  or  applied  exter- 
nally, resulted  in  the  establishment  of  the  fundamental  principle  of 
early  incision  to  permit  of  the  escape  of  infectious  material,  and  the 
use  of  the  tampon,  which  removed  these  materials^ by  its  capillarity. 

Bier  in  11)05  iiitro(hic((l  st  ill  another  method  by  which  it  may  be  pos- 


SUPPLEMENT   TO   THE   TKlvVTMENT   OF   ACUTE    INFLAMMATION     311 


sible  to  combat  infections.  In  the  Bier  treatment  an  attempt  is  made  to 
increase  the  natural  resistance  of  the  tissues  by  inducing  a  local  passive 
hypera^niia,  and  to  place  the  organism  in  a  condition  in  which  it  can 
resist  infection,  and  by  avoiding  large  incisions,  immobilizing  dressings, 
and  tampons,  and  by  early  motion  to  restore  the  function  of  the  diseased 
extremity. 

But  such  a  method,  in  which  the  greater  part  of  the  struggle  against 
infection  is  left  to  the  organism,  can  be  employed  with  safety  only 
when  the  infection  is  mild.  It  is  doubtful  whether  the  treatment  will 
suffice  in  severe  infections,  for  in  these  more  than  in  any  other  the  final 
results  depend  upon  the  resistance  of  the  organism,  which  only  rarely 
can  be  estimated  in  the  beginning  of  an  infection. 

Passive  hypera^mia,  according  to  Bier,  is  induced  by  the  application 
to  the  extremity  involved  of  a  thin  elastic  constrictor  6  cm.  in  width. 
The  constrictor  is  applied  near  the  trunk  over 
a  few  turns  of  a  gauze  bandage  or  about  the 
neck  under  slight  tension.  The  constrictor  is 
fastened  with  a  safety  pin,  or,  according  to 
Klapp,  by  cohesion  of  the  ends  of  the  con- 
strictor after  having  been  placed  in  water. 

The  constrictor  may  be  applied  at  higher  or 
lower  levels  several  times  during  the  day.  A 
piece  of  rubber  tubing  may  be  used  above  the 
shoulder  and  about  the  testicle,  and  an  elastic 
bandage  3  cm.  in  width  about  the  neck. 

The  constrictor  should  not  be  applied 
tight  enough  to  stop  the  circulation  or 
even  to  weaken  the  pulse,  the  object  be- 
ing merely  to  slow  the  blood  stream  and 
to  cause  a  dilatation  of  the  blood  vessels. 
When  properly  applied  the  extremity 
becomes  hot  and  oedematous,  and  the 
pain  in  the  inflammatory  area  rapidly 
subsides.  If  the  constrictor  is  too  tight 
the  pain  increases  in  severity.  It  is  difficult  to  maintain  the  proper 
degree  of  hypera?mia,  and  the  patient  must  be  continually  watched, 
especially  if  not  very  intelligent,  as  it  may  be  necessary  to  remove 
and  reapply  or  to  readjust  the  constrictor  several  times  during  a  treat- 
ment. Many  have  difficulty  in  maintaining  a  warm  hypera'inia  Avith 
an  acute  cpdema.  If  the  constrictor  exerts  too  great  compressitm  the 
nutritional  disturbance  resulting  fi-om  tlie  increased  stasis  injures  the 
tissues  and  reduces  their  natural  resistance. 

The  constrictor  in  the  beginning,  applied  daily,  may  be  allowed  to  re- 


FiG.  130. — lV\.\i)  Koii  I'KODifriNU  Pas- 
sive Hypkk.k.mia  Applied  to  the 
Arm.     (After  Bier.) 


312  WOUND   INFECTIONS  PRODUCED   BY   BACTERIA 

main  ten  hours,  later  as  long  as  twenty-two  hours.  AA^hen  it  is  removed 
the  extremity  is  elevated  or  suspended  in  order  to  lessen  the  oedema. 

Small  punctures  may  be  made  into  the  inflamed  area  to  assist  in  the 
treatment.  Large  incisions  are  employed  only  when  there  are  severe 
circulatory  disturbances  in  the  inflamed  area.  Incisions  are  made  when 
softening  has  occurred  and  there  is  an  accumulation  of  pus.  Tampons 
are  not  used,  however,  as  the  transudate  which  is  poured  out  in  such 
large  amounts  following  the  passive  hypera;mia  keeps  the  wound  open. 

Only  deep  wounds  are  drained.  The  pus  is  expressed  each  day  when 
the  dressings  are  changed.  From  the  first  day  active  and  passive  motion 
is  begun  (even  when  there  is  an  inflammation  of  tendon  sheaths  or  a 
joint),  the  object  being  to  obtain  as  good  functional  results  as  possible. 
For  the  same  reason  no  immobilizing  dressing  is  applied,  the  wound  being 
merely  covered  with  several  layers  of  gauze,  which  are  maintained  in 
position  by  a  loosely  applied  roller  bandage. 

The  method  has  been  reconnnended  for  the  treatment  of  all  kinds 
of  acute  inflammatory  processes,  especially  of  a  pyogenic  character,  of 
the  extremities,  head,  and  testicle  (lymphangitis,  phlegmons  of  all  kinds, 
felons,  suppuration  of  bones  and  joints,  gonorrheal  arthritis,  infected 
open  accidental-  and  operation-wounds),  and  to  hasten  the  separation  of 
necrotic  tissues,  etc.  Although  the  method  has  been  enthusiastically  re- 
ceived, there  are  some  serious  objections  to  it.  In  private  practice  it  is 
not  entirely  practical,  for  the  patient  must  be  watched  continually. 

According  to  Lexer's  experience  good  results  may  be  obtained  in  mild 
infections  which  do  not  progress  rapidly,  and  are  accompanied  by  little 
or  no  fever  if  the  treatment  is  instituted  during  the  first  few  days. 
These  infections,  however,  subside  completely  or  end  in  the  formation  of 
a  small  abscess,  which  rapidly  heals  when  a  small  incision  is  made,  just 
as  frequently  when  an  immobilizing  dressing  is  applied  and  moist  com- 
presses are  used.  Often,  however,  under  this  treatment,  the  inflammatory 
infill  rale  increases  in  size  (even  in  mild  cases  in  which  a  hyperaemia  has 
been  eai-ly  induced),  and  there  develops  still  more  rapidly  than  when 
p(mltices,  which  are  no  longer  used  to-day,  are  employed  an  acute,  rap- 
idly progressive  phlegmon  which  ruptures  into  and  invades  the  healthy 
siirroiniding  tissues.     The  local  inflammation  becomes  worse  and  extends. 

Phlegmons  of  the  tendon  sheaths  and  suppurative  arthritis  heal  with 
good  functional  results  if  the  hypersemia  is  induced  early.  It  is  well 
known  that  good  functional  results  havc^  been  obtained  in  these  cases 
by  tbe  usual  treatment,  but  good  functional  results  are  much  more  fre- 
(juent  wJien  l>iei''s  method  is  employed,  and  the  clinical  course  is  shorter 
than  when  eai'ly  incisions  and  dry  dressings  are  used,  but  the  treatnuMit 
must  l)e  continued  until  the  inflamnuition  has  completely  subsided  in 
order  to  prevent,  with  certainty,  recurrences. 


SUPPLEMENT  TO  THE  TREATMENT  OP  ACUTE   INFLAMMATION    3L3 

In  some  of  tlie  severe  cases  the  local  and  ueneral  condition  lias  become 
worse  even  when  the  hyperannia  has  been  induced  early.  I  am  con- 
vinced that  some  of  the  bad  results  that  I  have  seen  follow  this  treat- 
ment could  have  been  avoided  if  immediate,  early  incision  combined  with 
the  use  of  a  tampon  had  been  employed.  Some  of  the  bad  results  which 
I  have  had  may  be  briefly  mentioned:  (1)  Rapid  extension  of  the  in- 
flammation with  the  formation  of  a  large  inflammatory  infilti-ation  and 
abscesses;  (2)  rupture  of  the  abscesses  into  healthy  surrounding  tissues; 
(3)  general  infection  in  a  streptococcic  arthritis  of  average  severity  upon 
which  the  treatment  had  a  favorable  influence  for  one  week;  (4)  a  fatal 
ease  in  a  child  with  a  pneumococcic  infection  of  the  knee  joint.  In  the 
last  case  two  days  after  the  hypersemia  was  induced  the  temperature, 
which  had  been  101°  F.,  rose  to  over  104°  F.  with  symptoms  of  severe 
intoxication,  and  death  rapidly  followed. 

The  most  efl^ective  factor  in  the  treatment  is  not  the  bacteriolysis 
produced  by  an  accumulation  of  the  protective  substances,  which  may 
set  free  a  large  amount  of  endotoxins  injuring  the  tissues  and  the 
organism ;  not  the  dilution  of  the  toxins  by  the  oedema,  nor  the  increased 
absorption  which  follows  the  removal  of  the  constrictor;  but  the  mechani- 
cal flushing-  and  washing  of  the  inflamed  and  oedematous  tissues  by  the 
greatly  increased  amounts  of  transudate. 

Recent  large,  open,  accidental-wounds  are  cleansed  very  quickly  and 
heal  without  infection  if  an  hypera'mia  is  induced.  It  may  be  used  to 
advantage  in  the  treatment  of  inflammatory  infiltrations  before  they  have 
softened,  when  combined  with  large  enough  incisions  to  permit  of  the 
escape  of  the  transudate.  Passive  hypera^nia  acts  favorably  in  severe 
cases,  and  a  tampon  can  be  dispensed  with  if  large  incisions,  which  per- 
mit of  the  escape  of  the  infectious  materials,  are  made  before  the  hyper- 
femia  is  induced.  If  incisions  are  not  made  the  hyperamiia  may  do 
harm,  for  the  transudate,  like  Sehleich's  solution  when  used  in  acute  in- 
flannnations,  may  drive  the  bacteria  and  their  toxins  into  healthy  tissues 
and  favor  the  extension  of  the  inflammation. 

Therefore,  in  my  opinion  incisions  should  not  l)e  delayed  until  soften- 
ing has  occurred,  but  should  be  made,  especially  when  there  is  an  acute 
febrile  onset,  before  the  hyperamia  is  induced.  Cavities  containing  jnis 
should  be  opened  wide  in  order  to  permit  of  a  free  discharge  of  the  pus 
and  the  transudate  which  follows  the  application  of  the  consti-ictor.  Ihem- 
orrhage  must  naturally  be  controlled  by  a  tampon  before  the  hyperamia 
is  induced,  the  transudate  favoring  the  separation  of  the  gauze. 

Expression  of  the  pus  by  digital  pressure,  the  avoidance  of  innno- 
bilizing  dressings,  and  early  movement  of  the  diseased  extremity  are  not 
to  be  recommended.  Passive  hyperamia  is  not  to  be  recommended  in 
the  treatment  of  acute  lymphangitis. 


314 


WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 


Klapp  has  recommended  for  the  treatment  of  small  inflammatory 
foci,  especially  those  occurring  upon  the  trunk,  an  apparatus  from  which 
the  air  may  be  exhausted  which  resembles  somewhat  the  dry  cup  formerly 
employed  very  extensively.  Naturally  the  pressure  exerted  by  the  edges 
of  the  glass  should  be  removed  from  the  acutely  inflamed  area. 


Fig.   131. — Suction  Apparatus  for  Mastitis.      (After  Klapp.) 

The  suction  glasses  (Fig.  131),  which  are  made  in  difl'erent  forms 
and  sizes,  should  be  applied  daily  for  about  three  quarters  of  an  hour 
in  all.  After  being  in  position  for  five  minutes  the  glass  should  be 
removed  for  from  one  to  three  minutes  and  then  reapplied.  The  appa- 
ratus should  be  boiled  before  using,  and  vaseline  should  be  applied  to 


Fig.   1.32. — Suction  Apparatus  for  Fki.ons.     (After  Klapp.) 

the  skin  where  the  rim  comes  in  contact  in  order  to  prevent  the  ghiss 
from  falling  off.  The  vacuum  should  not  be  too  low,  and  the  glass  should 
not  be  allowed  to  remain  in  position  too  long,  as  hf^morrhages  may  occur 
into  the  tissues. 

Furuncles  and  carbuncles  with  necrotic  centers,^  small  inflammatory 
foci  on  the  fingers,  in  the  breast  and  lymph  nodes,  which  have  already 


SUPPLEMENT   TO   THE   TREATMENT   OF   ACUTE    INFLAMMATION     315 

softened  and  have  been  opened  by  a  small  incision,  suppurating  ha'nia- 
tonias — in  short,  all  encapsulated  foci  not  accompanied  by  fever  and 
without  a  tendency  to  progress — may  be  quickly  rid  of  pus  and  infectious 
materials  by  this  suction  treatment,  without  any  added  injury  to  the 
tissues.  Large  incisions  may  be  avoided  in  tliis  way  and  the  time  re- 
quired for  healing  shortened.  Beginning  mild  inflammations,  so  com- 
mon upon  the  hands  of  physicians,  may  be  easily  controlled.  Cautious 
treatment  with  a  suction  apparatus  is  to  be  recommended  for  all  cases 
of  this  character.  According  to  my  experience,  however,  it  should  not 
be  recommended  for  the  treatment  of  inflammatory  infiltrations  which 


Fig.   133. — Suction  Glass  for  a  Furuncle.     (After  IClapp.) 

have  not  softened  and  which  are  accompanied  by  fever  and  have  a  tend- 
ency to  extend  rapidly.  An  inflammation  of  this  character,  which  after 
earh'  incision  and  use  of  the  dry  tampon  subsides  in  from  one  to  tw(i 
days  with  an  immediate  decline  in  the  temperature,  may  extend  and  be 
associated  with  the  formation  of  large  amounts  of  pus  and  an  extensive 
destruction  of  tissue  when  this  treatment  is  employed.  The  local  con- 
dition is  aggravated  and  the  time  required  for  healing  is  lengthened, 
and  even  after  the  inflammation  has  subsided  the  induration  pei-sists 
and  is  more  extensive  than  when  early  incisions,  not  combined  with  the 
suction  treatment,  are  made. 

Literature. — Bestelmeyer.  Erfahrungen  iiber  die  Behandlung  ukut  enlziiiull. 
Prozesse  mit  Stauimgshyi)eramie.  Miinchn.  med.  Wocheiischr.,  1906,  p.  46 L — liter. 
Behandlung  akuter  Eiterungen  mit  Stauuiigshj'perainie.  Ibid.,  190.5,  p.  201 ; — 
Die  Hyperamie  als  Heilinittel.  Leipzig,  \'ogel. — Klapp.  Ueber  die  Behandlung 
entziindl.  Erkrankungen  niittelst  Saugapparaten.  Miinchn.  med.  Wochenschr.,  I'JO.i, 
p.  740. — Lexer.  Zur  Behandlung  akuter  Entziindungen  mittelst  Stauungshj-peni- 
mie.  Ibid.,  1906,  No.  14; — Die  Behandlung  der  septischen  Infektion.  Zeitschr, 
f.  firztl.,  Fortbildung,  1906. — Rami.  ITeber  die  Behandlung  akuter  Eiterungen  mit 
Stauungshyperamie.  Wiener  klin.  Woehenschr.,  1906,  No.  4. — Wolf-Eisiu-r.  Die 
Biersche  Stauungshyperamie  vom  Standjiunkt  der  Endoxinlehre.  Miinch.  med. 
Woehenschr.,  1906,  p.  1102. — [Siehe  auch  die  Diskussion  iiber  das  Thema  in  den  Chir.- 
Kongr.-^'erhandl.,  1906.] 


316  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

CHAPTER   VIII 

SURGICAL   H/EMATOLOGY 

HEMATOLOGY,  though  but  recently  introduced  into  the  fields  of  diag- 
nosis and  prognosis,  has  given  results  of  such  great  value  that  a  very 
brief  consideration  of  its  more  important  branches  as  related  to  sur- 
gery is  here  presented.  A  more  systematic  study  of  the  various  changes 
of  the  blood  in  many  surgical  conditions  will  not  only  lead  to  more 
accurate  diagnoses  and  methods  of  treatment,  but  will  help  to  clear  up 
many  of  the  obscure  problems  in  connection  with  the  pathogenesis  of 
disease.  ]\Iuch  has  been  written  recently  upon  the  value  of  blood  ex- 
aminations. No  one  questions  the  great  value  of  a  positive  blood  cul- 
ture or  other  results  equally  decisive.  Negative  findings  and  those 
changes  which  are  not  so  constant — e.  g.,  the  presence  or  absence  of  a 
leucocytosis — have  led  to  widely  different  conclusions.  This  much  is 
certain,  however,  that  in  the  hands  of  competent  men  the  examination 
of  the  blood,  when  correlated  with  the  clinical  symptoms,  will  lead  to 
the  identification  of  many  puzzling  conditions. 

For  the  technical  methods  involved,  the  reader  is  referred  to  works 
on  laboratory  diagnosis  and  ha?matology. 

BACTERIOLOGY  OF  THE   BLOOD 

The  bacteriological  examination  of  the  blood  is  frequently  the  means 
of  identifying  many  puzzling  septic  conditions.  Many  descriptions 
given  previously  convey  erroneous  ideas  as  to  the  technic  involved  and 
as  to  the  interpretation  of  the  results.  The  statements  frequently  made 
that  the  demonstration  of  streptococci  in  the  blood  in  cases  of  septic 
infections  means  a  fatal  issue,  and  that  the  presence  of  pneumococci 
and  typhoid  bacilli  in  the  blood  in  cases  of  lobar  pneumonia  and 
typhoid  fever  respectively  is  to  be  regarded  as  a  very  bad  prognostic 
sign  are  erroneous.  These  statements  are  usually  based  either  upon 
insufficient  data  or  upon  results  obtained  by  a  crude  technic.  It  can 
readily  l)e  undci-stood  how  the  demonstration  of  a  bacteraemia  by  meth- 
ods wholly  ina(le(|uate — unless  the  bacterium  sought  for  is  present  in 
very  large  nTniil)ers,  as  occurs  fre<(uently  in  overwhelming  infections — 
will  l(';i(l  to  the  erroneous  conclusion  that  invasion  of  the  blood  stream 
in  septic  iui'ccfions  means  a  fatal  issue. 

Ixeccut  perfections  in  the  technic  of  blood-culturing  have  demon- 
str-ated  beyond  reasonable  doubt  that  most  specific -infections  are  in  real- 
ity bacitenemias. 


SURGICAL   HEMATOLOGY  317 

A  study  of  the  results  of  blood  cultures  is  interesting.  The  earlier 
observations  in  typhoid  fever,  scarlet  fever,  and  streptococcic  infec- 
tions, in  rheumatism,  endocarditis,  pneumonia,  and  other  septic  condi- 
tions show  a  low  percentage  of  positive  findings,  while  the  more  recent 
works  show  a  very  much  higher  percentage  of  positive  results.  In 
nearly  every  instance  the  difference  in  the  results  is  due  to  improved 
methods.  These  include  the  use  of  larger  quantities  of  blood  for  inocu- 
lation, and  more  particularly  the  use  of  more  favorable  culture  media. 

In  scarlet  fever  streptococciemia  has  been  demonstrated  during  life 
by  Ilektoen,  Jochmann,  and  others. 

Baginsky  and  Sommerfeld  demonstrated  streptococci  in  the  blood 
of  every  one  of  eighty-two  cases  of  scarlet  fever  examined  post  mortem. 

Bertelsmann  found  numerous  bacteria  in  the  blood  during  urethral 
fever  which  followed  the  passage  of  sounds  in  cases  of  stricture.  In 
most  instances  they  rapidly  disappeared,  but  in  two  cases  the  bac- 
tera?mia  persisted. 

In  a  case  of  acute  follicular  tonsilitis  Rosenow  isolated  the  strepto- 
coccus pyogenes  from  the  blood  during  the  initial  chill,  but  not  subse- 
quently. In  two  cases  of  empyema  which  recovered,  cultures  from  the 
pus  and  blood  yielded  streptococci  pyogenes  of  high  virulence  in  one  case 
and  pneumococci  in  the  other. 

Five  cases  of  puerperal  sepsis  out  of  eight  examined  contained  strep- 
tococci in  the  blood.  Two  of  the  cases  with  the  streptococctemia  and 
one  in  which  the  blood  cultures  were  negative  died;  the  rest  made 
imeventful  recoveries. 

In  lobar  pneumonia,  pneumococci  have  been  demonstrated  in  the 
blood  in  a  large  percentage  of  cases  by  Badnel,  Prochaska,  Frankel, 
Rosenow,  and  others.^ 

Positive  blood  cultures  have  been  obtained  in  a  small  percentage  of 
eases  by  Cole,  Libman,  Kohn,  and  Sello.  Rosenow,  Badnel,  and  Frankel 
attribute  very  little  prognostic  significance  to  the  mere  demonstration 
of  pneumococci  in  the  blood,  finding  them  alike  in  the  fatal  and  non- 
fatal cases,  while  Cole,  Libman,  Kohn,  and  SeHo  regard  a  pneumo- 
coccannia  as  a  bad  prognostic  sign,  because  of  their  higher  percentage 
of  positive  findings  in  the  fatal  cases. 

In  this  connection  it  should  be  stated  that  blood  cultures  in  cases 
of  post-operative  pneumonia  are,  as  a  rule,  negative  unless  the  pneu- 
monia is  of  the  frank,  outspoken,  lobar  tj'pe,  when  the  pneumococcus 
is  usually  obtained  in  pure  cultures. 

In  typhoid  fever  the  bacillus  tyjjhosus  has  been  cultivated  from  the 

'  The  total  number  of  cases  Rosenow  has  examined  thus  far  is  300  and  the  high 
percentage  of  positive  findings  above  reported  is  maintained. 


318  WOUND    INFECTIONS   PRODUCED   BY   BACTERIA 

blood  in  about  eighty  per  cent  of  cases  by  Cole,  Schotmiiller,  Auerbach, 
and  others. 

The  highest  percentages  of  positive  cultures  are  obtained  during 
the  first  week  of  the  infection,  often  before  the  appearance  of  the  agglu- 
tination reaction,  thus  making  it  a  most  valuable  diagnostic  procedure 
in  the  differentiation  of  septic  conditions  which  resemble  typhoid  fever. 

In  paratyphoid  fever  similar  results  have  been  obtained.  Among 
other  conditions  in  which  a  blood  culture  is  often  the  means  of  making 
a  correct  diagnosis  should  be  mentioned  malignant  endocarditis,  gon- 
orrheal sepsis,  cerebro-spinal  fever,  and  other  septic  states  of  obscure 
character. 

A  positive  blood  culture  in  any  infection  is  final  from  a  diagnostic 
viewpoint.  On  the  other  hand,  a  negative  result  is  of  doubtful  value 
and  does  not  prove  the  absence  of  micro-organisms  in  the  blood.  By  a 
simple  modification  of  the  technic,  Frankel  and  Kinsey  (Jour.  Am.  Med. 
Assn.,  1904,  759)  changed  their  percentage  of  positive  findings  in 
pneumonia  from  twenty  to  eighty  in  the  same  epidemic.  Similar  re- 
sults have  been  obtained  in  typhoid  fever. 

Anyone  with  an  understanding  of  bacteriological  principles  can 
make  a  blood  culture.  It  is  a  perfectly  harmless  procedure  when  prop- 
erly carried  out.  I'here  is  no  danger  of  thrombosis.  The  following 
steps  should  be  followed : 

1.  Preparation  of  the  Arm. — Constrict  the  arm  by  means  of  an  elastic 
rubber  tube  to  the  extent  of  producing  venous  stasis,  care  being  exer- 
cised not  to  interfere  with  the  arterial  circulation.  This  is  likely  to 
happen  in  severe  septic  conditions  when  the  pulse  is  of  small  volume 
and  of  low  tension.  Locate  the  median  basilic  or  median  cephalic  vein. 
The  point  selected  for  the  puncture  should  be  near  the  median  line, 
so  as  to  avoid  the  external  and  internal  cutaneous  nerves.  The  former 
lies  just  beneath  the  outer  end  of  the  median  cephalic  vein,  while  the 
latter  crosses  the  median  basilic  at  its  inner  end. 

The  skin  should  be  sterilized  with  ninety-five  per  cent  alcohol.  The 
superficial  epithelium  should  be  rubbed  off.  If  this  is  done  thoroughly, 
there  need  be  no  fear  of  infecting  the  patient  or  of  contaminating  the 
culture  media.  The  more  elaborate  methods  for  sterilization  are  un- 
necessary, and  as  they  are  time-consuming  they  are  undesirable,  espe- 
cially for  roiitiTie  work. 

2.  The  Puncture  and  Withdrawal  of  the  Blood. — The  venous  punc- 
ture is  usually  easy,  provided  a  needle  with  a  sharp  point  is  used. 
Those  fitting  a  glass  syringe  of  the  Tjuer  type,  having  a  capacity  of 
not  less  than  10  c.c,  are  very  satisfactory.  For  sterilizing  the  syringe 
and  needle  the  autoclave  is  to  be  preferred.  The  syringe  and  needles 
slioiild   be  boiled  for  at  least  one  half  hour  in  order  to  prevent  con- 


SURGICAL   HEMATOLOGY  319 

tamination.  After  the  syrinue  is  filled  the  eonstrietor  should  he.  re- 
moved before  withdi-a\vin<;-  the  needle.  IModei-ate  pivs-sure  should  be 
made  over  the  site  of  the  puncture  with  a  dry  sterile  sponge  until  the 
blood  clots.  This  may  be  done  by  the  patient  while  the  operator  inocu- 
lates the  media. 

The  blood  clot  which  forms  is  sufficient  protection  for  the  small, 
punctured  wound.  A  small  collodion  dressing'  may  be  applied,  but  it 
is  unneceasary.  The  minute  blood  clot  exposed  to  the  air  protects  the 
vein  more  securely  against  bacterial  infection  than  when  covered  with 
collodion. 

3.  The  Inoculation  of  the  Media. — The  strictest  precautions  should 
be  observed,  for  it  is  during  this  procedure  that  contamination  is  most 
apt  to  occur.  The  needle  which  has  been  passed  through  the  skin  is 
apt  to  carry  with  it  a  smaller  or  larger  number  of  staphylococci,  no 
matter  what  method  of  sterilization  is  used.  It  should  therefore  be 
removed  and  inoculation  made  through  the  sterile  glass  end  of  the 
syringe.  The  tubes  or  flasks  containing  the  media  should  be  held  as 
nearly  horizontal  as  possible  during  inoculation.  The  mouths  should 
be  flamed  thoroughly  and  the  cotton  plugs  replaced  as  soon  as  possible. 

The  character  of  the  media  is  of  the  greatest  importance.  Litnuis 
milk  and  beef  broth  are  the  most  favorable  for  routine  work.  The 
reaction  of  the  latter  should  be  one  per  cent  acid  to  phenolphthalein  or 
neutral  to  litmus. 

The  broth  should  be  made  from  meat  and  not  from  the  extract  of 
beef.  It  should  be  sterilized  by  fractional  sterilization  instead  of  by 
the  autoclave.  This  is  particularly  important  when  a  pneumococcus 
infection  is  suspected. 

Dilution  of  the  blood,  while  of  lesser  importance,  should  be  taken 
note  of.  A  convenient  way  to  control  this  factor  in  routine  work  is 
to  take  four  flasks,  each  containing  50  c.c.  of  the  media,  and  add  approxi- 
mately one,  two,  three,  and  four  or  more  c.c.  of  blood  to  each  flask, 
respectively.  The  inoculated  media  are  then  placed  in  the  thermostat. 
At  the  end  of  twenty-four  hours  the  cultures  usuallj^  show  the  presence 
of  a  growth  if  the  result  is  to  be  positive.  Very  exceptionally,  positive 
results  are  obtained  first  after  three  or  four  days  have  elapsed. 

EXAMINATION  OF   BLOOD   FOR   HiEMATOZOA 

Attention  to  the  microscopic  examination  of  the  blood  for  animal 
parasites  in  puzzling  septic  conditions  will  frequently  lead  to  a  correct 
diagnosis. 

Pernicious  malaria  without  definite  paroxysms  and  with  an  atypical 
course  often  resembles  typhoid  fever,  meningitis,  uraMuic  coma,  pcrni- 


320  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

cioiis  anaemia,  tuberculosis,  and  dysentery.    An  examination  of  the  blood 
will  usually  reveal  the  malarial  oraanism. 

In  tropical  countries  the  spirillum  of  Obermeier,  Hlaria  sanguinis 
hominis  and  trypanosoma  Gambiensi  should  be  searched  for.  All  of 
these  occur  in  the  peripheral  blood,  while  the  Leishman-Donovan  bodies 
of  tropical  splenomegaly  are  usually  obtained  by  splenic  puncture,  since 
they  appear  only  exceptionally  in  the  general  circulation. 

LEUCOCYTOSIS 

The  term  leucocytosis  has  come  to  mean  the  presence  in  the  blood 
of  an  increased  number  of  white  blood  corpuscles  of  the  same  variety 
morphologically  as  those  in  normal  blood.  Usually  the  greatest  in- 
crease is  in  the  polymorphonuclear  neutrophiles,  and  this  is  sometimes 
spoken  of  as  a  polymorphonuclear  leucocytosis. 

A  distinct  diminution  of  leucocytes  is  often  spoken  of  as  a  leuco- 
penia  or  hypoleucocytosis  in  contrast  to  hyperleucocytosis,  indicating 
an  excess  of  cells. 

Much  experimental  and  clinical  work  has  been  done  in  recent  years 
upon  the  significance  and  value  of  inflammatory  and  infectious  leuco- 
cytosis. 

The  work  of  Metschnikoff  and  his  school  upon  phagocytosis  and 
allied  subjects  has  taught  us  to  look  upon  a  leucocytosis  in  many  in- 
fecticms  not  only  as  an  expression  of  the  intensity  of  the  irritant,  but 
as  a  positive  means  of  defense.  The  investigations  of  Wright  and 
Douglas,  ITektoen,  Ruediger,  Rosenow,  Potter,  Dittman,  Bradley,  and 
others  have  thi'own  much  light  upon  the  mechanism  involved.  They 
have  shown  that  destruction  of  various  bacteria  in  the  test  tube  is  a 
result  of  the  combined  action  of  the  scrum,  "  opsonin,"  and  the  living 
cell,  the  leucocyte.  They  have  pointed  out  that  opsonification,  phago- 
cytosis, and  iiitraphagocytic  digestion  probably  play  an  important  role 
in  combating  certain  infections. 

If  a  leucocytosis  were  constantly  present  in  the  same  disease  and 
always  absent  in  certain  others,  and  if  the  maxim  that  "  the  higher  the 
leucocytosis  the  more  favorable  the  j)rognosis  "  were  always  true,  there 
would  be  no  occasion  for  the  diverse  opinions  held  by  diffcT'ent  ob- 
servers as  to  the  vnlne  of  leucocytosis  as  a  prognostic  sign.  But  since 
a  high  leucocytosis  may  be  an  expi-ession  of  a  severe  infection  and  at 
the  same  time  be  an  index  of  resistcince,  and  because  in  overwhelming 
infections  it  often  fails  to  apjoear  fi-om  the  beginning  or-  later  disap- 
pears, there  is  ainple  reason  why  authoi-s  dififer  as  to  its  value. 

When  we  remember  that  a  j)athologi('al  leucocytosis  may  be  inflam- 
matory or  infectious,  j)ost-lia'morrhagic  or  toxic  in  nature  or  the  result 


SURGICAL   HEMATOLOGY  321 

of  malignant  disease,  it  is  obvious  that  enumeration  of  the  leucocytes 
can  help  us  in  the  diagnosis  and  prognosis  of  disease  generally,  and 
especially  in  the  diagnosis  and  prognosis  of  many  surgical  condititms, 
only  when  correlated  with  the  other  clinical  data.  When  this  is  done, 
leucocytosis  is  often  of  the  greatest  value  and  furnishes  the  necessary 
mi&sing  link  in  a  chain  of  evidence  re(iuisite  for  the  correct  diagnosis 
of  some  obscure  internal  infection. 

The  degree  of  leucocytosis  varies  greatly  from  day  to  day  in  many 
cases  of  sepsis.  A  single  leucocyte  count  is  of  very  little  more  value 
than  a  single  temperature  or  pulse  record.  Leucocytosis  should  be  stud- 
ied from  day  to  day  or  oftener  in  curves  much  in  the  same  way  as  the 
temperature  and  pulse  are. 

If  this  is  done  and  the  observations  are  correlated  with  the  clinical 
symptoms,  the  leucocyte  curve  will  not  infreciuently  furnish  the  data 
necessary  to  decide  when  to  institute  surgical  interference  in  a  given 
case  and  when  not  to  do  so. 

Before  rendering  a  final  decision  as  to  the  significance  of  a  leuco- 
cytosis the  various  forms  of  purely  physiological  leucocytosis  must  be 
ruled  out.  A  digestion  leucocytosis  is  usually  at  its  maxinnim  about 
four  hours  after  a  meal.  The  increase  rarely  exceeds  3,500  cells.  It 
does  not  occur  when  leucocytosis  is  already  present. 

Leucocytosis  is  of  very  little  value  in  the  differential  diagnosis  of 
ulcer  and  carcinoma  of  the  stomach,  because  it  fails  to  appear  in  ulcer 
quite  as  commonly  as  in  beginning  carcinoma. 

The  leucocytosis  of  the  newborn,  of  pregnancy,  and  of  parturition,  as 
well  as  that  following  certain  mechanical  and  thermal  influences,  must 
also  be  borne  in  mind. 

Busse,  King,  and  others  have  shown  that  a  post-operative  leuco- 
cytosis of  from  5,000  to  10,000  leucocytes  per  cubic  millimeter  in  from 
six  to  thirty-six  or  forty-eight  hours  is  normal  provided  it  is  not  main- 
tained. A  persistent  leucocytosis  in  aseptic  operations  nnist  be  looked 
upon  as  indicating  infection,  defective  drainage,  spreading  inflamma- 
tion, or  htemorrhage. 

The  significance  of  Ijnnphocytosis,  eosinophilia,  myelfemia,  iodophilia, 
and  other  cellular  changes  of  the  blood  are  omitted  here  because  of  their 
relatively  limited  value  to  the  surgeon. 

COAGULATION   OF   THE   BLOOD 

The  time  required  for  the  coagulation  of  the  blood  after  withdrawal 
from  the  body  is  dependent  upon  a  number  of  conditions.  The  coagu- 
lation is  slower  when  the  blood  is  obtained  from  a  deep  cut  or  fi'om 
venous  puncture  than  when  it  flows  from  a  superficial  cut.     Coagula- 


322  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

tion  is  dependent  upon  the  amount  of  blood  allowed  to  flow,  upon  the 
pressure  used,  upon  the  temperature,  and,  to  a  considerable  degree, 
upon  the  nature  of  the  containing  receptacle. 

The  time  of  day  makes  a  diliference,  the  coagulation  time  being  per- 
ceptibly shorter  in  the  morning  than  in  the  afternoon.  The  test  should 
not  be  made  shortly  after  a  meal,  since  the  time  of  coagulation  is  influ- 
enced by  certain  foods  and  drugs.  Uniformity  of  technic  and  the  neces- 
sity of  always  stating  the  method  employed  in  the  report  of  cases  cannot 
be  too  strongly  emphasized. 

Too  much  reliance  should  not  be  placed  upon  the  coagulation  time. 
Only  relatively  great  deviations  from  the  normal  should  be  considered, 
for  it  has  been  proven  that  coagulation  outside  of  the  body  is  not  the 
same  process  as  intravascular  coagulation.  Welch  justly  says  that  "  we 
cannot  bring  the  appearance  of  coagulation  in  the  living  vessel  into 
direct  parallel  with  coagulation  of  the  blood  as  ordinarily  under- 
stood." 

Extravascular  coagulation  unquestionably  is  dependent  to  some  de- 
gree upon  the  fibrin  content,  while  intravascular  coagulation  is  quite 
independent  of  it.  This  is  indicated  by  the  fact  that  in  cachexia, 
anaemia,  and  typhoid  fever  thrombosis  is  common,  yet  the  fibrin  con- 
tent of  the  blood  is  low,  w'hile  in  pneumonia  and  acute  articular  rheu- 
matism, where  the  fibrin  content  is  high,  thrombosis  is  rare. 

The  time  required  for  a  clot  to  form  in  wounds  (the  point  of  great- 
est interest  to  surgeons)  corresponds,  however,  relatively  closely  to  the 
time  of  coagulation  as  determined  by  laboratory  methods ;  hence  their 
value.  ^ 

The  coagulation  time  is  prolonged  in  many  cases  of  jaundice,  an- 
«emia,  anasarca,  ha^moglobineemia,  hirmophilia,  purpura,  asphyxia,  acute 
alcoholism,  cobra  poisoning,  and  in  some  toxic  conditions. 

It  is  interesting  to  note  here  that  the  lengthened  coagulation  time 
in  jaundice  appears  to  depend  not  upon  the  jaundice  per  se,  but  rather 
upon  the  associated  toxaemia,  hasmoglobiiuTmia,  and  excessive  anaemia. 
Fatal  post-operative  hannorrhage  is  more  prone  to  occur  in  cases  of 
malignant  disease  of  the  biliary  passages  with  jaundice  than  in  the 
obstructive  jaundice  associated  with  cholelithiasis. 

Coagulation  is  hastened  by  the  administration  of  relatively  small 
doses  of  the  calcium  salts;  retarded  wlieii  these  salts  are  given  in  too 
large  doses  or  for  too  long  a  time.  From  60  to  90  grains  daily  of  cal- 
cium chlorid  for  three  or  four  days  will  usually  promote  clotting  in 
a  patient  whose  coagulation  is  (h^laycnl. 

•  I'^or  the  various  methods  used  the  reader  is  referred  to  works  on  ha'inatology  and 
laboratory  diagnosis, 


SURGICAL   HEMATOLOGY  323 

In  easef?  of  long'-staiKliiiir  janndioc  witli  dolayed  coaiiulation  the 
coagulation  time  should,  when  possible,  be  brought  within  five  minutes 
before  an  operation  is  performed. 

Early  in  typhoid  fever,  delayed  coagulation  may  predispose  to  in- 
testinal haemorrhage,  while  in  the  later  stages  of  this  infection  the 
coagulability  of  the  blood  may  be  so  increased  as  to  favor  thrombosis. 
This  tendency  to  rapid  coagulation  is  believed  to  be  due  to  the  exces- 
sive quantity  of  calcium  salts  in  the  blood  of  the  convalescent  typhoid, 
the  result  of  the  prolonged  milk  diet.  Wright  and  Knapp  suggest,  in 
order  to  prevent  thrombosis  in  this  disease,  the  partial  decalcification 
of  the  milk  by  the  addition  of  sodium  citrate  as  soon  as  the  danger  of 
hEemorrhage  is  over. 

HAEMOGLOBIN  AND   ERYTHROCYTES 

A  relatively  greater  diminution  in  the  haemoglobin  than  in  the  red 
cells  occurs  in  the  symptomatic  anaemias  attending  the  chronic  consti- 
tutional diseases,  in  chlorosis,  infections,  hfemorrhagie  disorders,  and  the 
various  toxic  states. 

Because  the  hasmoglobin  reduction  in  these  conditions  is  greater 
than  that  of  the  red  cells,  the  amount  of  hfemoglobin  per  red  corpuscle 
is  less  than  normal.  This  condition  is  known  as  a  low  color  index. 
The  color  index  is  obtained  by  dividing  the  percentage  of  hanuoglobin 
by  the  percentage  of  red  cells  present.  It  is  important  in  all  cases 
of  anaemia  to  determine  this  point,  since  the  graver  anaemias  and  leu- 
ka^nias  have  a  normal  or  even  a  high  color  index;  the  low  hannoglobin 
reading  in  these  cases  being  due  to  the  reduction  in  the  number  of 
red  cells. 

Pallor  of  the  skin  is  not  necessarily  due  to  anaemia.  It  may  be  due 
to  a  deficient  cutaneous  circulation,  the  result  of  valvular  disease,  myo- 
carditis, or  vasomotor  disturbances,  and  hence  should  never  be  used 
as  an  index  of  the  hamoglobin  content  of  the  blood. 

In  the  interpretation  of  hamoglobin  values  it  nnist  be  remembered 
that  concentration  of  the  blood  may  account  for  abnormally  high  fig- 
ures, while  in  dilute  hydramie  blood  the  reverse  occurs,  the  gain  or  loss 
in  either  instance  paralleling  the  fluctuations  of  the  erythrocytes. 

Individuals  with  a  low  haemoglobin  reading  do  not  bear  general 
anasthesia  and  the  loss  of  blood  incident  to  an  operation  well.  Bier- 
freund,  ]\Iikulicz,  and  others  believe  that  a  haemoglobin  percentage  below 
thii'ty  or  forty  contraindicates  a  general  anasthetic.  Numerous  reports 
of  successful  operations  under  general  anasthesia  in  cases  in  Avhich  the 
hamoglobin  percentages  ranged  between  fifteen  and  thirty  have  been 
made,  but  all  agree  that  operations  should  be  performed  as  a  life-sa\nng 


324  WOUND   INFECTIONS   PRODUCED   BY   BACTERIA 

measure  only  when  the  haemoglobin  is  so  low.  Nowhere  in  the  realm 
of  surgery  does  the  skill  of  the  operator  and  anaesthetist  count  for  so 
much. 

Bergmann,  Bauman,  Aborti,  and  others  have  shown  that  iron  is  the 
most  useful  blood  builder  for  patients  deficient  in  haemoglobin,  hence  it 
should  be  given  freely  in  secondary  anaemias.  Arsenic  stimulates  indi- 
rectly the  haemogenic  centers,  and  is  therefore  of  greater  value  when 
the  deficiency  in  haemoglobin  is  the  result  of  a  diminution  in  the  num- 
ber of  erythrocytes.  It  has  little  or  no  effect  in  exciting  directly  a 
haemoglobin  increase. 

CRYOSCOPY 

The  freezing  point  (expressed  by  the  Greek  delta.  A)  of  normal 
blood  ranges  betweeji  —0.56°  and  —0.58°  C,  while  normal  urine  freezes 
between  —0.9°  and  —0.2°  C.  These  fluids  are  no  exception  to  the  law 
that  the  greater  the  molecuhir  concentration  of  liquids  the  lower  the 
freezing  point. 

Surgically,  cryoscopy  is  used  chiefly  in  determining  the  integrity  of 
the  kidneys. 

Koranyi  showed  that  in  diseases  of  the  kidney  with  renal  insuf- 
ficiency the  A  of  the  blood  falls,  while  that  of  the  urine  correspond- 
ingly rises,  the  blood  becoming  surcharged  with  excrementitious  mat- 
ter, which  the  crippled  kidneys  fail  to  discharge. 

Kiimmel,  Lindeman,  and  others  assert  that  a  freezing  point  below 
—  0.58°  or  certainly  —0.6°  is  a  distinct  contraindication  to  a  nephrec- 
tomy, because  they  believe  that  when  this  figure  is  obtained  both  kid- 
neys are  too  extensively  implicated  to  insure  adequate  elimination  when 
one  kidney  is  removed.  This  view  has  been  revised  because  Tieken, 
Loeb  and  Adrian,  Rovsing,  and  others  have  shown  that  unilateral  le- 
sions may  cause  decided  abnormalities  of  the  A,  while  bilateral  lesions 
may  exist  without  any  such  change.  Their  studies  have  shown  that 
cryoscopy  alone  is  of  doubtful  value  in  determining  the  state  of  renal 
activity,  because  other  factors  modify  the  molecular  concentration  of  the 
blood  and  urine,  such  as  circulatory  stasis,  dependent  upon  cardio- 
vascular, hepatic  diseases,  abdominal  neoplasms,  and  anaemia  from  any 
cause.  A  lowering  of  the  A  of  the  blood,  while  not  accepted  univer- 
sally as  a  contraindication  to  nephrectomy,  should  alw^ays  make  the  sur- 
geon cautious.  'I'his  question,  as  well  as  other  clinical  features  of  cryos- 
copy, has  been  extensively  studied  by  Tieken,  Ogsten,  Casper  and  Ricli- 
ter,  and  Rinker. 

LiTEUATTJRE. — Budnel.  Rev.  de  M6d.,  1899,  p.  70. — Baginsky  and  Sommerfeld. 
Arch.  f.  Kinderheilkunde,  1902.— Cole.  Bull.  Johns  Hopkins  Hosp.,  1901,  XII,  203; 
1903,  XIII,  im.—IIektoen.     Jour.  A.  M.  A.,  1903,  XL,  685;  Jour.  Infectious  Dis.,  1906, 


SURGICAL   HEMATOLOGY  325 

III,  lo6. — Jochmann.  Zeitschrift  f.  klin.  Med.,  1905,  LV,  316. — Kinsey.  Jour.  A.  M. 
A.,  1904,  759.— Kohn.  Deutsch.  med.  Wochenschrift,  1897,  XXllI,  186.~Libman. 
Jour.  Med.  Research,  1901,  I,  84. — Prochuska.  Centralblatt  f.  inner.  Med..  1900,  XXI, 
1145. — Rosetww.  Amer.  Jour,  of  Obstetrics,  1904,  702;  Jour.  Infectious  Disea.ses,  1904, 
280;  1906,  III,  683. — Schotmiiller.  Deutsch.  nied.  Wochenschrift,  1900,  Aug.  9. — Sello. 
Ztschrft.  f.  klin.  Med.,  1898,  XXXVI.  112.— Wright  and  Douylus.  Proceedings  of  Roy. 
Soc,  1903,  LXXII,  357;  1904,  LXXXIII,  128. 


III.      WOUND     INFECTIONS    OF     DIFFERENT 

ORIGINS    AND    SURGICAL    INFECTIOUS 

DISEASES 

CHAPTER    I 

WOUND   INFECTIONS    CAUSED   BY   POISONS 

Poisoning  by  Insects,  Snakes,  etc. — Intoxications,  varying  in  sever- 
ity, may  follow  the  sting  or  bite  of  a  number  of  different  insects  (bee, 
wasp,  hornet,  spider,  gnat,  flea,  bedbug,  and  others).  Besides  the  local 
inflammatory  reaction  which  follows  the  sting  or  bite,  there  may  be 
general  symptoms,  such  as  superflcial  respirations,  rapid  pulse,  faint- 
ness,  collapse,  and  vomiting.  These  general  symptoms  are  most  apt  to 
develop  when  a  man  or  animal  has  been  attacked  by  a  swarm  of  bees  or 
wasps,  and  the  lesions  are  distributed  over  a  large  part  of  the  surface 
of  the  body.  Usually  the  general  and  local  symptoms  subside  rapidly, 
but  the  patient  may  feel  weak  and  feeble  for  several  days.  Death  has 
followed,  however,  a  single  sting  by  a  bee  or  wasp. 

The  sting,  which  is  situated  in  the  posterior  end  of  the  bodies  of 
bees  and  w^asps,  together  with  the  poison  bladder,  is  frequently  left  in 
the  wound,  and  should  always  be  removed.  The  wound  should  be 
touched  with  a  dilute  solution  of  ammonia  in  order  to  neutralize  the 
poison,  Avhich  contains  an  acid  (probably  formic  acid).  The  same  method 
should  be  employed  in  the  treatment  of  stings  by  the  European  scor- 
pion, which  are  very  similar  to  stings  inflicted  by  bees  and  wasps.  The 
application  of  naphthalene  has  been  recommended  in  the  treatment  of 
mosquito  bites   (Voges). 

["  Poisonous  snakes  are  widely  distributed  in  all  countries  of  the 
temperate,  and  especially  of  the  torrid,  zones.  In  the  United  States 
about  .seventeen  species  of  rattlesnakes  and  ten  species  of  copperheads 
atid  moccasins,  vipers,  coral,  and  hai'letiuin  snakes,  etc.,  are  classed  as 
poisonoiKS;  with  them  a  Texan  reptile  known  as  the  (iila  monster  is  also 
classed.  In  South  America,  Central  America,  Africa,  the  West  Indies, 
and  Australia  many  venomous  reptiles  are  found.  In  Europe  the  adder 
nnd  vipf'r  are  dreaded,  while  in  Iiidia  much  iitt(Mition  has  been  paid  to 
llii'  Tli;iMatopliidi;i.  Ilic  col)!-;!  having  furnislied  the  venom  upon  which 
32G 


WOUND    INFECTIONS  CAUSED    BY   TOISONS  327 

the  work  of  Fraser,  Calmette,  and  others  has  been  based." — Keen's 
"  Surgery,"  Vol.  I,  pp.  539  and  5-10.] 

["  The  poison  apparatus  of  snakes  consists  of  a  secretory  gland 
on  each  side  which  conniiunicates  with  a  tubular  fang  by  means  of 
a  duct.  In  the  passive  state  the  fangs  are  directed  backward  on  the 
roof  of  the  mouth,  but  when  the  animal  strikes,  their  points  are  made 
to  project  forward  and  the  poison  is  forced  thrt)ugh  the  canals  by  mus- 
cular compression  of  the  sac.  The  venom  is  a  glandular  secretion." 
— Ricketts,  "  Infection,  Inununity,  and  Serum  Therapy,"  pp.  264  and 
265.] 

Bites  caused  by  poisonous  snakes  may  be  recognized  by  two  small 
punctured  wounds  lying  side  by  side,  while  a  zigzag  wound  is  produced 
by  non-poisonous  snakes. 

Action  of  Snake  Venoin. — Snake  venom,  like  the  toxins  produced  by 
bacteria,  dissolves  red  blood  corpuscles,  and  contains  two  toxic  albu- 
minous bodies  (toxalbumins)  which  produce  a  local  and  genera]  re- 
action. 

["  The  venoms  of  different  snakes  vary  a  great  deal  in  their  toxic 
properties.  The  most  important  constituents  are  those  which  attack 
the  nervous  system  (neurotoxin),  the  blood  corpuscles  (haniiolysins  and 
luemagglutinins),  and  the  endothelium  of  blood  vessels  causing  hiemor- 
rhages  (h^morrhagin,  an  endotheliotoxin).  The  neurotoxin  causes 
death  b}^  paralysis  of  the  cardiac  and  respiratory  centers.  The  htpmo- 
lysin  appears  to  be  of  less  importance  as  a  cause  of  death. 

"  The  venoms  of  the  cobra,  water  moccasin,  daboia,  and  some  poison- 
ous sea  snakes  are  essentially  neurotoxic,  although  they  have  strong  dis- 
solving powers  for  the  erythrocytes  of  some  animals.  In  studying  the 
hiemolytic  powers  of  the  venoms  of  cobra,  copperhead,  and  rattlesnake, 
Flexner  and  Noguchi  found  cobra  venom  to  be  the  most  ha^nolytic,  and 
that  of  the  rattlesnake  the  least.  They  attribute  the  toxicity  of  rattle- 
snake poison  chiefly  to  the  action  of  luvmorrhagin.  The  same  authors 
studied  the  action  of  different  venoms  on  the  cells  of  various  animals, 
and  by  absorption  experiments  found  independent  cytotoxins  for  the 
testis,  liver,  kidney,  and  blood.  Not  only  was  there  a  distinct  cyto- 
toxin  for  each  organ  of  an  animal,  but  also  for  the  same  organ  of  dif- 
ferent animals,  results  which  speak  for  a  remarkable  complexity  of 
venom.     Certain  venoms  contain  a  leucocytic  toxin. 

Proteolytic  Ferments. — "  That  venoms  contain  proteolytic  ferments 
is  shown  by  their  ability  to  digest  gelatin  and  fibrin.  This  power  may 
be  related  to  the  softening  of  the  muscles  which  has  been  noted  clinic- 
ally in  cases  of  poisoning.  The  rapid  decomposition  of  the  body  which 
follows  death  by  snake-poisoning  is  associated  witli  a  decrease  in  the 
bactericidal  power  of  the  blood,  which,  according  to  Flexner  and  No- 


328  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

guchi,  depends  on  fixation  of  the  complement  by  the  venom." — Ricketts, 
"  Infection,  Immunity,  and  Serum  Therapy,"  pp.  265  and  266.] 

Symptoms :  Local  and  General. — The  local  symptoms  consist  of  pain- 
ful swelling  of  the  tissues  surrounding  the  wound,  which  develops  soon 
after  the  bite  is  received.  The  skin  covering  the  swollen  tissues  is  not 
discolored  at  first,  but  petechite  and  suggillations  soon  develop.  In  a 
short  time  the  swelling  becomes  very  extensive,  and  within  half  an  hour 
the  extremity  becomes  twice  its  normal  size.  The  lymphangitis  and 
lymphadenitis  which  frequently  develop  are  due  to  the  absorption  of 
the  venom ;  suppurative  phlegmonous  inflanunation  to  secondary  infec- 
tion with  pyogenic  bacteria.  Necrosis  and  gangrene  of  the  oedematous 
tissue  are  frecpiently  produced  by  a  too  long-continued  and  too  great 
constriction  of  the  extremit}^  or  by  subsequent  putrefactive  infections. 
In  a  few  hours  after  the  injury  the  general  symptoms,  consisting  of 
dizziness,  faintness,  fever,  headache,  small  rapid  pulse,  dyspncea,  the 
feeling  of  anxiety,  vomiting,  diarrh(ra,  with  or  without  blood,  and  col- 
lapse, develop.  In  the  majority  of  cases  these  symptoms  disappear  in  a 
few  days  (on  an  average  of  nine  days,  according  to  W.  K.  Miiller)  and 
the  patient  recovers,  although  a  marked  weakness  may  persist  for  a 
long  time.  Death  due  to  cardiac  Aveakness  or  asphyxia  occurs  in  from 
three  to  nine  per  cent  of  the  cases.  The  coagulability  of  the  blood  is 
reduced  in  these  fatal  cases,  and  numerous  haemorrhages  are  found  in 
the  viscera  and  intestinal  mucous  membranes. 

Comparative  Toxicity  of  Venoms. — The  local  and  general  symptoms 
following  bites  inflicted  by  the  rattlesnake  (America)  and  the  cobra 
(Asia,  Africa)  are  much  more  severe  than  those  following  bites  inflicted 
by  the  viper,  and  end  fatally  more  frequently.  The  mortality  follow- 
ing bites  inflicted  by  these  two  snakes  is  about  twenty  per  cent.  In 
India  more  than  20,000  people  die  each  year  as  the  result  of  snake  bites. 
Innnediate  death  may  follow  injury  of  a  vein,  with  direct  injection 
of  the  venom  into  the  circulation.  The  cases  of  ordinary  severity  end 
fatally  in  a  few  days,  the  patient  becoming  delirious  and  unconscious, 
and  tetanic  convulsions  developing.  In  chronic  cases  death  may  follow 
the  after-effects  of  the  venom  (cachexia,  tendency  to  oedema,  hoemor- 
rhagic  diathesis)  after  months  or  years.  It  is  important  to  know  that 
the  venom  in  nniseum  specimens  never  becomes  inactive. 

Treatment:  Local  and  General. — The  laity  have  recognized  for  a 
long  time  that  the  synq)t()ms  following  siuike  bites  are  due  to  absorption 
of  venom,  and  liave  foi'inulati^l  two  iinportant  rnles  to  ])revent  or  lessen 
llic  absoi'pl  ion  ol'  llic  jxtisonous  iiia1('ri;il  :  (1)  H'o  imnicdiali'ly  suck  the 
wound,  I'eiiioving  Ihc^  venom,  or  to  express  it  by  digital  pressure  applied 
to  the  tissnes  ahont  the  wonnd;  (2)  to  tie  off  the  injured  part  (for 
example,  an  extremity)  close  to  the  bite  as  soon  as  possible,  and  in  this 


WOUND   INFECTIONS  CAT'SEl)   BY   POISONS  329 

way  prevent  the  absorption  of  the  venom  until  some  other  treatment 
eau  be  instituted.  It  is  dangerous  to  suek  a  wound  unh'ss  one  has  a 
special  apparatus  of  some  kiiid  or  can  protect  the  lips,  as  fissures  may 
become  infected.  Venom  lias  no  effect  upon  healthy  mucous  mem- 
branes, and  even  if  introduced  into  the  stomacli   is  rendered  liarmless. 

The  hiyman  has  outlined  the  work  for  the  physiciaM,  whose  duty 
it  is  to  excise  the  wound  as  soon  as  possible  and  to  make  large  incisions 
into  the  inflamed,  and,  if  a  constrictor  has  been  applied,  (edematous  tis- 
sues, providing  in  this  way  an  escape  for  at  least  a  part  of  the  venom. 
The  constricting  strap  or  rope  which  the  patient  himself  or  a  friend  may 
have  applied  should  not  be  reuioved  until  incisions  have  been  nuide 
and  considerable  serum  has  exuded,  for  in  this  way  the  absorption  of 
considerable  amounts  of  venom  which  might  prove  dangerous  is  pre- 
vented. Incised  wounds  secrete  more  profusely  than  those  covered  with 
a  crust  or  membrane ;  therefore  a  knife  is  preferred  to  caustics  and  the 
actual  cautery  in  treating  wounds  of  this  character.  Treatment  by 
incisions  is  more  reliable  than  the  methods  intended  to  neutralize  the 
toxic  properties  of  the  venom  by  subcutaneous  injections  of  chemical 
agents,  such  as  a  one  half  per  cent  solution  of  potassium  pi'rmanganate 
or  a  freshly  filtered  solution  of  chlorinated  lime.  Cupping  and  scari- 
fication may  be  combined  with  incisions.  Amputation  of  the  smaller 
parts  is  sometimes  indicated.  Of  course  the  incised  wovnuls  should  be 
dressed  aseptically,  innnobilizing  dressings  applied,  and  the  part  ele- 
vated if  possible. 

If  there  is  cardiac  weakness,  stimulants  should  be  administei'cd. 
Subcutaneous  injections  of  camjihor  and  transfusions  of  physiological 
salt  solution  (0.9  per  cent)  act  favorably.  Large  doses  of  alcohol 
(punch,  mulled  wine,  cognac,  whisky)  are  in  great  reputt^  among  the 
laity. 

Antitoxic  Sera. — Calmette  was  the  first  to  attempt  to  produce  an 
antitoxic  serum  for  the  treatmimt  of  snake  bites.  |"  Calmette 's  anti- 
venin  is  obtained  by  innnunizing  horses  with  a  mixture  of  venoms 
(eighty  per  cent  cobra,  twenty  per  cent  viperine  venom)  which  are  at- 
tenuated before  injection.  Six  months  are  required  to  produce  a  strong 
antivenin.  The  claim  of  Calmette  that  his  serum  is  effective  against 
all  snake  venom  is  erroneous.  It  neutralizes  those  venoms  the  toxicity 
of  which  depends  largely  on  neurotoxins  and  hannolysins,  but  has  little 
influence  on  rattlesnake  poison,  the  essential  toxin  of  which  is  luvmor- 
rhagin.  Antivenin  for  rattlesnake  and  water  moccasin  may  be  pre- 
pared by  innnunizing  with  the  corresponding  venoms  which  have  been 
attenuated  by  weak  acids.  Noguchi  has  produced  serum  of  such  strength 
that  it  promises  to  be  of  practical  value  in  the  treatment  of  rattlesnake 
bites. 


330  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

"  As  indicated  previously,  the  action  of  venom  is  preceded  ])y  no 
appreciable  incubation  period ;  hence  an  antitoxin  to  be  elTective  mast 
be  administered  not  later  than  a  few  hours  after  the  l)ite  has  occurred. 
Noguchi  found  in  relation  to  antivenin  for  the  rattlesnake  that  the 
amount  necessary  to  save  experimental  animals  was  quadrupled  three 
hours  after  intravenous  injection  of  two  fatal  doses  of  venom.  Fortu- 
nately the  venom  is  less  toxic  when  introduced  subcutaneously. " — 
Ricketts,  "  Infection,  Immunity,  and  Serum  Therapy,"  pp.  267  and 
268.]  The  bile  of  poisonous  snakes  has  an  antitoxic  action  (Fraser)  ; 
likewise  the  serum  of  animals  immunized  against  tetanus  and  hydro- 
phobia (Roux). 

Indian  Arrow  Poison. — Wound  infections  may  be  produced  by  the 
poisoned  points  of  arrows  used  by  savages.  Vegetable  (strychnin,  anti- 
arin  in  Asia,  strophanti! us  in  Africa)  or  animal  poisons  (rattlesnake 
venom  mixed  with  decomposing  meat  or  blood  in  America)  are  most 
frequently  employed  for  this  purpose.  These  poisons  paralyze  the  heart 
or  cause  tetanic  convulsions.  As  a  rule,  death  follows  their  action  in 
a  short  time.  If  the  poison  is  sucked  out  of  the  wound  immediately 
the  life  of  the  individual  may  be  saved.  It  is  important  to  use 
stimulants  when  the  poison  acts  upon  the  heart.  Curare,  the  arrow 
poison  most  highly  valued  by  the  Indians,  paralyzes  all  the  voluntary 
nniscles. 

Cadaveric  Poisoning. — The  wound  infections  caused  by  cadaveric 
poisons  are  purely  toxic  in  character,  and  are  much  rarer  than  w\^s 
formerly  considered  to  be  the  case.  Although  cadaverin,  Avhich  be- 
longs to  the  ptomains,  has,  according  to  Grawitz,  a  pyogenic  action, 
the  acute,  severe  infections  which  follow  injuries  received  during  post- 
mortem examination  of  fresh  cadavers  are  caused  by  highly  virulent 
bacteria.  The  latter  are  rapidly  absorbed  and  produce  more  frequently 
acute,  severe,  general  infections  than  local  suppurating  lesions.  ]\Iost 
of  these  severe  infections  follow  injuries  received  during  post-mortem 
examinations  of  subjects  dying  of  virulent  bacterial  infections  (peri- 
tonitis, meningitis,  general  infections).  The  wounds  received  during 
the  dissection  of  and  operations  upon  old  cadavers  are  rarely  followed 
even  by  local  inflammation  if  the  haemorrhage  from  the  wound  follow- 
ing compression  of  the  surrounding  tissue  is  free  and  a  dressing  is 
applied,  which  prevents  secondary  infection.  Billroth  has  recommended 
concentrated  acetic  acid  as  the  best  caustic  for  this  class  of  wounds. 

Literature. — Brenning.  Die  Vergiftungen  (lurch  Schlangon.  Enke,  Stuttgart, 
1895. — Brieger.  Ueber  Pfeilgifte  aus  Deutsch-Ostafrika.  Berl.  kliti.  Wochenschr., 
1002,  p.  277. — Calmctte.  Comptes  reiulus,  1800,  Nr.  4;  Miinch.  inecl.  Woohensclir., 
IH'M't,  p.  O.'iO. — Fraser.  Die  antitoxischon  l*'igen,schaftcii  der  Galle  von  SchUuigcn. 
Wi(!ncr  iiicd.  Bl;i((cr,   1807,  ]).  481. — Grawitz.     Ikihvr  die  Bcdeutung  des  Kadaverins 


HYDKOrUOBlA  331 

fiir  (lie  Entstehiuig  der  Eiterung.  Virchow's  Arch.,  Bd.  110,  1887,  p.  1. — Husemann. 
Jiehiindlung  der  Vergiftungen.  Handbuch  der  spez.  Therapie  innerer  Krankheiten 
von  Peuzoldt  und  Stintzung,  1895,  Bd.  2. — Lamb.  Die  Seruinbehandlung  der  Schlangen- 
bisse.  Lancet,  Nov.  5,  1904. — Lewin.  Die  Pfeilgifte.  Histor.  ii.  experim.  I'ntor- 
suchungen.  Reimer,  Berlin,  1903. — W.  K.  Mailer.  Die  Verletzungen  durch  Schlangen- 
biss  in  Pommern.     I.-D.,  Greifswald,  1895. 


CHAPTER    II 

HYDROPHOBIA    (lYSSA,    RABIES) 

Hydrophobia  as  it  occurs  in  man  is  an  acute  wound  infection  which 
invariably  proves  fatal.  It  is  transmitted  to  man  by  the  bite  of  a  rabid 
animal,  most  frequently  (ninety  per  cent)  by  the  dog,  or  in  its  saliva, 
which  in  some  way  is  introduced  into  fresh  wounds. 

Virus  of  Hydrophobia:  Negri  Bodies. — Nothing  definite  is  known  con- 
cerning the  virus  of  hydrophobia.  Negri  in  1903  first  described  round 
bodies  -1  to  10  ju,  in  size  in  the  nervous  system  of  animals  dying  of 
the  disease.  These  bodies  are  found  within  the  large  ganglion  cells, 
and  are  especially  numerous  in  the  horn  of  Amnion  and  in  the  cells 
of  the  cerebellum.  They  are  also  found,  but  not  in  as  large  numbers, 
in  the  cells  of  the  medulla  oblongata,  the  spinal  cord,  and  spinal  gan- 
glia. Negri's  findings  have  been  confirmed  by  Yolperino,  Bertarelli, 
Schiffmann,  Maresch,  and  others.  These  bodies  may  be  regarded  as 
the  most  characteristic  findings  in  animals  and  men  dying  of  hydro- 
phobia. Further  investigation  must  decide  whether  Negri  is  correct 
in  regarding  them  as  protozoa  and  as  the  specific  cause  of  the  disease. 

Distribution  of  the  Virus. — It  has  been  demonstrated  by  animal  ex- 
periments that  the  bi-ain,  spinal  cord,  and  peripheral  nerves  contain  the 
virus.  It  has  even  been  demonstrated  in  the  saliva  of  animals  before 
they  have  shown  symptoms  of  the  disease.  The  virus  apparently  passes 
from  the  M'onnd  along  injured  nerve  trunks  (Babes,  di  Vestea-Zagari, 
Wyssokowitch,  and  others).  ["  Experimental  work  shows  conclusively 
that  the  virus  is  conveyed  to  the  central  nervous  system  by  means 
of  the  peripheral  nerves,  and  that  the  infection  is  closely  associated 
with  the  wounding  of  nerves.  It  has  been  shown  that  if  wounding  of 
nerves  is  entirely  avoided,  as  in  inti'aperitoneal  injections  into  rabbits 
(IMarx)  the  full  virulent  nervous  tissue  may  be  used  for  immunization." 
— Ricketts,  "  Infection,  Innnunity,  and  Serum  Therapy,"  p.  517.1  The 
infection  develops  most  rapidly  aud  most  frequently  after  the  injection 
of  small  amounts  of  the  brain  or  spinal  cord  of  patients  or  animals 
dying  of  the  disease  into  the  subdural  si)ace.     Infection  does  not  follow 


332  WOUND    INFECTIONS   OF    DIFFERENT   ORKJINS 

subcutaneous  injections,  and  the  results  of  intravascular  injections  are 
inconstant.  This  partly  demonstrates  that  the  virus  is  taken  up  by  and 
extends  along  injured  nerves. 

Susceptibility  of  Different  Animals. — All  warm-blooded  animals  are 
susceptible.  The  disease  iiiay  be  transmitted  to  man  by  the  dog,  wolf, 
cat,  and  fox.     Direct  infection  from  man  to  man  is  not  known. 

Hydrophobia  in  Dogs. — In  dogs  the  incubation  varies  from  three  to 
five  weeks.  The  prodromal  stage  is  characterized  by  restlessness,  loss 
of  appetite,  nausea,  and  irritabilit}^  Then  in  a  few  days  the  symptoms 
characteristic  of  the  second  stage  of  the  disease  become  pronounced. 
["  According  to  Bollinger  the  initial  or  prodromal  stage  lasts  from 
one  half  to  two  or  three  days,  and  the  stage  of  real  madness,  irritation, 
or  maniacal  stage  lasts  three  to  four  days." — Tillman's  "  Text-book  of 
Surgery,"  I,  398.]  The  virus  may  be  transmitted  to  man  and  animals 
through  the  saliva  before  there  are  any  symptoms  of  the  disease.  The 
bite  of  an  animal  which  is  apparently  healthy  may  therefore  carry  with 
it  the  danger  of  infection. 

Two  forms  of  hydrophobia  may  be  distinguished  in  dogs — tJte  raging 
and  the  paralytic.  According  to  Pasteur,  the  raging  form  develops  when 
the  virus  attacks  chiefly  the  brain,  and  the  paralytic  form  when  it  attacks 
chiefly  the  spinal  cord.  In  the  convulsive  or  maniacal  form  the  disposi- 
tion of  the  dog  changes  suddenly.  The  animal  becomes  more  irritable, 
attempts  to  bite  other  animals  or  surrounding  objects,  runs  confusedly 
about,  and  utters  long-drawn-out  howls,  emaciates  rapidly,  and  shows 
a  preference  for  indigestible  things,  such  as  wood,  earth,  and  faeces, 
A  pharyngeal  spasm  develops  at  every  attempt  to  drink,  therefore  the 
name  hydrophobia,  meaning  "  fear  of  water,"  has  been  given  the  dis- 
ease. The  third  stage  (stage  of  paralysis)  develops  upon  the  third  or 
fourth  day.  The  hind  legs  first  become  paralyzed.  The  paralysis  later 
extends  to  other  muscles,  and  on  from  the  third  to  the  sixth  day  con- 
vulsions develop  and  death  occurs.  An  animal  which  develops  hydro- 
phobia never  recovers.  The  paralytic  form  is  still  more  rapid;  the 
paralysis  (particularly  of  the  muscles  of  the  extremities,  mastication, 
and  deglutition)  develops  earlier,  as  there  is  no  stage  of  excitement. 

Hydrophobia  in  Man. — Hydrophobia  in  man  is  characterized  by  a 
long  period  of  incul)ation,  generally  from  twenty  to  sixty  days.  It  va- 
ries from  fifteen  days  to  six  months.  A  longer  period  of  incubation  than 
six  months  is  extremely  rare.  Hydrophobia  does  not  follow  every  bite 
by  a  rabid  dog,  as  the  clothes  afford  some  protection  against  the  infec- 
tious saliva.  Only  a  small  proportion  of  those  bitten  by  rabid  animals 
(according  to  Babes,  not  one  third;  according  to  others,  still  less)  de- 
velop the  disease.  Hydrophobia  follows  less  fre(-iuently  bites  of  pro- 
te(;ted  parts  of  the  body,  more  often  bites  of  the  head  and  face. 


HYDROPHOBIA  333 

Clinical  Course. — The  prodromal  stage  begins  with  pain  in  the 
wound  or  scar,  which  radiates  along  the  nerves  supplying  the  sur- 
rounding area.  Sometimes  the  scar  becomes  reddened,  sometimes  when 
the  wound  is  not  healed  the  granulations  are  unhealthy.  Loss  of  appe- 
tite, headache,  melancholia,  restlessness,  anxiety,  sleeplessness,  slight 
dysphagia  and  dj^spncea,  sometimes  early  aversion  to  liquids,  in  spite 
of  great  thirst,  and  slight  temperature  indicate  the  beginning  of  the 
disease.  After  a  few  hours  or  days,  painful  pharyngeal  spasms  develop 
at  every  attempt  at  drinking  and  eating.  These  pharyngeal  spasms, 
which  finally  may  be  even  provoked  by  the  sight  of  a  drinking  glass, 
render  the  swallowing  of  food,  even  the  swallowing  of  saliva  impossible, 
and  are  the  principal  symptoms  of  the  hydrophobic  stage  which  is  char- 
acterized by  an  increased  reflex  excitability.  At  this  time  the  skin 
and  sense  organs  are  hypersensitive,  and  any  irritation,  such  as  stroking 
or  blowing  upon  the  skin,  loud  noises,  strong  light,  etc.,  produces  a 
dyspna?ic  condition  and  clonic  spasms  of  all  the  muscles.  The  pupils 
become  dilated  when  the  skin  is  irritated  or  the  auditory  nerve  is  stinui- 
lated  (Schaffer).  AVlien  this  increased  excitability  extends  from  the 
spinal  cord  and  medulla  to  the  brain,  the  reflexes  are  abolished,  the 
dilated  pupil  does  not  react,  the  urine  is  discharged  involuntarily,  and 
delirium  develops.  Sometimes  extensive  paralysis  occurs  (lumbar  and 
cervical  paraplegias)  and  sometimes  the  last  or  convulsive  stage  may 
begin  with  violent  and  persistent  vomiting  and  be  characterized  by  con- 
vulsions. The  patient  rapidly  becomes  exhausted,  a  high  fever  devel- 
ops, and  death  occurs,  most  frecpiently  between  the  second  and  fourth 
days  of  the  disease.     Consciousness  may  be  retained  until  the  end. 

Pathological  Anatomy. — Inflammatory  and  degenerative  changes 
have  been  described  in  the  motor  centers  of  the  central  nervous  system, 
especially  in  the  spinal  cord  (acute  myelitis).  These  changes  are  most 
advanced  in  the  segments  which  correspond  to  the  nerves  primarily  in- 
volved (Schaffer).  [Babes  has  described  peculiar  perivascular  nodules 
in  the  medulla  and  spinal  cord  composed  of  lymphoid  cells;  van  Ge- 
huchten,  a  proliferation  of  the  endothelium  surrounding  the  ganglion 
cells.     Degenerative  and  atrophic  changes  occur  in  the  latter.] 

Diagnosis. — Hydrophobia  may  be  mistaken  for  head  tetanus,  as 
pharyngeal  spasms  occur  in  the  latter  also.  Hysteria  must  be  consid- 
ered in  making  a  diagnosis. 

Treatment. — In  the  treatment  of  bites  of  rabid  or  supposedly  rabid 
animals  an  attempt  should  be  made  to  render  the  virus  harmless  as  soon 
as  possible.  Excision  of  the  wound,  amputation  of  small  parts,  and 
open  treatment  of  the  wound  are  most  efficacious.  Cauterization  of  the 
wound  is  not  safe,  as  the  eschar  prevents  the  discharge  of  wound  secre- 
tion, and  the  retained  virus  develops  beneath  it.     The  same  thing  hap- 


334  WOUND   INFECTIONS  OF   DIFFERENT   OUIGINS 

pens  when  the  primary  wound  or  the  one  following  its  excision  is 
sutured.  The  edges  of  large  and  deep  wounds,  the  tissues  of  which  are 
contused  and  lacerated,  should  be  trimmed  off  and  a  tampon  which 
provides  for  the  discharge  of  the  secretion  should  be  inserted. 

Because  of  the  longer  incubation  period  local  treatment  is  of  more 
value  in  man  than  in  animals.  Babes  found  that  in  order  to  prevent 
the  development  of  the  disease  in  animals,  the  wound  must  be  cauter- 
ized with  a  Paquelin  cautery  not  later  than  five  minutes  after  infection. 

If  the  disease  has  developed,  narcotics  should  be  given  to  control 
the  painful  spasms.  Hourly  subcutaneous  injections  of  curare  (one 
fifth  to  one  half  grain)  have  been  recommended  (Penzoldt).  Rectal 
and  subcutaneous  injections  of  physiological  salt  solution  should  be 
given  to  control  the  thirst. 

The  disease  has  almost  disappeared  from  Germany  and  England. 
The  police  regulations  against  stray  and  suspected  animals  are  very 
rigid,  and  there  are  laws  which  provide  for  the  muzzling  of  dogs.  Ac- 
cording to  M.  Kirschner  there  were,  on  an  average,  only  four  deaths 
a  year  from  hydrophobia  in  Prussia  in  the  period  between  1889  to  1899. 
In  England  there  have  been  no  deaths  for  several  years.  In  America 
hydrophobia  is  still  common.  In  Chicago  from  fifteen  to  twenty  deaths 
occur  each  year. 

The  long  incubation  period  in  man  is  taken  advantage  of  in  the 
Pasteur  treatment,  as  an  immunity  may  be  established  against  the  virus 
before  the  symptoms  develop  and  the  disease  may  be  prevented.  Pas- 
teur gave  the  name  of  street  virus  {virus  de  rue)  to  that  obtained  from 
the  nervous  system  of  dogs  in  which  the  disease  develops  spontaneously. 
AVhen  the  street  virus  is  injected  subdurally  into  rabbits,  they  develop 
the  disease  after  two  or  three  weeks.  When  this  virus  is  passed  through 
a  number  of  rabbits  the  incubation  period  is  reduced  finally  to  six  days. 
It  is  impossible  to  reduce  the  incubation  period  below  six  days,  and  the 
virus  obtained  from  the  nervous  tissue  of  such  an  animal  is  extremely 
virulent.  It  is  called  the  fixed  virus  (virus  fixe).  In  the  Pasteur  method 
this  virus  is  gradually  attenuated  by  drying  the  spinal  cord.  The  virus 
obtained  after  drying  the  cord  for  fourteen  days  is  the  weakest  and  is 
no  longer  active  for  rabbits.  Dogs,  which  are  more  susceptible  than 
man,  may  be  rendered  immune  against  highly  virulent  virus,  if  bouillon 
emulsions  of  a  fourteen  day  old  cord,  then  a  thirteen,  twelve,  and  so  on 
are  injected  daily;  in  other  words,  if  the  virulence  of  the  virus  injected 
is  gradually  increased  each  day. 

The  Pasteur  treatment  is  the  only  one,  according  to  our  present 
knowledge,  which  will  prevent  the  development  of  the  disease.  It 
cannot  l)e  relied  upon  when  the  incul)ation  period-  is  short  (about  two 
weeks),  as  is  fr('(niently  the  case  in  bites  of  the  face  and   in  those  in- 


TETANUS:  LOCKJAW  335 

flieted  by  wolves,  or  when  treatment  is  instituted  late,  so  that  only  two 
or  three  weeks  elapse  before  the  syiiiptonis  (Icvcloj).  However,  if  the 
injections  are  given  in  rapid  snecession,  an  innnunity  against  the  strong- 
est virus  may  be  established  as  earl}'  as  the  third  day,  and  cures  have 
repeatedly  been  made.  Ten  c.c.  of  the  emulsion  should  be  injected 
subcutaneously  each  time  in  the  hypochondrium.  After  the  protective 
inoculations  have  been  completed  the  blood  contains  protective  sub- 
stances (Kraus  and  Kreisl). 

Mortality. — The  mortality  has  been  considerably  reduced  since  peo- 
ple bitten  by  rabid  or  supposedly  rabid  dogs  have  been  subjected  to  the 
Pasteur  treatment.  Pottevin  estimates  the  mortality  among  13,817  pa- 
tients treated  in  Paris  as  0.5  i^er  cent,  while  the  mortality  among 
patients  not  treated  is  not  lower  than  10  per  cent.  Ilogyes  gives  the 
mortality  of  those  who  received  treatment  as  0.85  per  cent,  of  those 
who  did  not  as  14.14  per  cent.  In  the  dangerous  wolf  bites,  90  per 
cent  of  which  are  followed  by  the  disease,  the  results  following  early 
treatment,  a  mortality  of  from  10  to  15  per  cent  are  very  favorable 
(Babes). 

Injections  of  blood  serum  obtained  from  immunized  animals  have 
also  been  made  with  success   (Balx'S,  Tizzoni,  Schwarz). 

Literature. — Babes.  Studien  iiber  die  Wutkrankheit.  Virchow's  Arch.,  Bd.  110, 
1887,  p.  562; — Ueber  die  Behandlung  von  300  von  wiitendcn  AVcUfen  Gebissenen. 
Zeitschr.  f.  Hygiene,  Bd.  47,  1904,  p.  179; — Behandlung  der  Wutkrankheit  des 
Menschen.  Im  Handb.  der  spez.  Therapie  von  Penzoklt  u.  Stintzing,  1903,  Bd.  1; 
Bertarelli.  Die  Xegrischen  Korpercben  im  Xervensystem  dor  Avutkranken  Tiere,  ihr 
diagnostischer  Wert  und  ihre  Bedeutung.     Zentralbk  f.  Bakteriok,  Bd.  37.     Abstract. 


CHAPTER    III 

TETANUS  :    LOCK-JAW 

NicOLAiER  in  1884  produced  fatal  tetanus  in  mice,  rabbits,  and 
guinea  pigs  by  infecting  them  with  garden  eai'tli,  in  which  he  had  dem- 
onstrated a  bacillus  with  a  somewhat  rounded  end.  Kosenbach  (1885) 
f(mnd  a  similar  bacillus  in  the  wound  of  a  patient  sick  with  tetanus. 
Kitasato  (1889),  using  anaerobic  culture  media,  was  the  first  to  obtain 
pure  cultures  of  the  bacillus  and  to  produce  with  the  cultures  experi- 
mental tetanus. 

Bacillus  of  Tetanus. — The  tetamis  bacillus  is  a  slender,  slightly  mo- 
tile organism  whieh  develops  a  terminal  spore,  and  for  this  rea.son  the 
l)acillus  with  its  spore  resembles  a  dfumstick.  The  bacillus  frequently 
develops  filamentous  forms  in  cultures.     It  stains  readily  with  the  ordi- 


336 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


Fig.  I'.i-i. — Tkianus  15acilli. 


nary  stains  and  also  by  Gram's  niethod.  The  bacillus  is  widely  dis- 
tributed in  the  ground,  and  is  found  as  far  as  30  era.  below  the  sur- 
face, being  carried  probably  to  this  depth  in  the  dung  of  animals,  in 

which  it  is  frequently  found.  Ap- 
parently the  bacilli  find  conditions 
favorable  for  growth  in  the  intes- 
tines of  animals,  but  tetanus  does 
not   develop   from   the   intestine,   as 

k-^_^ "    '    '       «   \    «  t  \     feeding    experiments    have    demon- 
•  ^A-^^  »^    strated.      Of   the  domestic  animals. 

Hie  horse,  cow,  and  sheep  develop 
tlie  disease  most  frequently  after  in- 
jury (or  after  castration). 

The  bacilli  are  obligatory  an- 
aerobes, and  grow  best  at  98.5°  F. 
Yellow  colonies  having  irregular  off- 
shoots which  grow  out  into  the  me- 
dium appear  in  gelatin  and  agar 
on  the  second  day.  Gelatin  about  stab  cultures  slowly  liquefies  and  gas 
is  formed.     Bouilhm  is  clouded.    All  cultures  have  a  disgusting  odor. 

Susceptibility  of  Different  Animals. — Guinea  pigs,  mice,  and  rabbits 
are  best  suited  for  exi)eriniental  purposes.  Fatal  tetanus  is  easily  pro- 
duced in  these  animals  by  the  injection  of  virulent  cultures.  Cultures 
become  inactive  when  heated  for  five  minutes  at  149°  F.,  and  are  ren- 
dered toxin  free,  as  the  toxins  secreted  by  tetanus  bacilli  are  destroyed 
by  heat.  The  toxin-free  cultures  still  contain  viable  spores,  but  are 
active  only  when  injected  in  large  amounts.  The  bacilli  must  there- 
fore be  injected  with  their  toxins  to  obtain  results.  If  old  cultures, 
rich  in  toxins,  or  foreign  bodies  to  which  bacilli  are  attached,  are  em- 
ployed, a  fatal  tetanus  develops  after  an  incubation  period  of  from 
one  to  three  days.  As  a  rule,  the  bacilli  do  not  extend  beyond  the 
wound,  and  onh^  in  rare  eases  have  they  been  demonstrated  in  the  vis- 
cera (von  Oettingen  and  Zumpe). 

Tetanus  Toxins, — Filtered  cultures,  and  bouillon  cultures  from 
which  the  bacilli  have  been  removed,  are  active,  as  they  contain  the 
toxins  which  have  been  secreted  by  the  bacilli.  Tlu'se  are  soluble  in 
water  and  can  be  precipitated  by  sodium-annuonia  sul])hate  (Buchner) 
or  zinc  chloi-id  (Bricger  and  Boer).  Dry  pi'eparations  of  the  toxins 
which  ai'c  more  useful  for  experimental  ])urposes  may  be  made  from 
the  preci])itate.  According  to  Ehrlich  and  JMadscn  there  are  two  toxins. 
They  fouud  in  bouillon  cultures  ietaHospaniin,  which  has  a  strong  affin- 
ity for  nervous  tissues  and  produces  the  nuiscular  spasms,  and  teta- 
nolysin,  which  dissolves  red  blood  corpuscles. 


TETANUS:    LOCKJAW  S'.^T 

Tlie  strength  of  the  toxin  is  dependent  upon  the  virulence  of  the 
bacilli.  The  virulence  of  the  bacilli  is  remarkably  increased  by  sym- 
biosis with  other  bacteria,  especially  by  putrefactive  processes  in  the 
wound  (A.  Schiitze). 

In  order  to  demonstrate  the  bacilli  in  a  wound  the  penetrating  for- 
eign body  or  a  particle  of  dirt  should  be  transferred  to  an  experimental 
animal.  If  bacilli  are  present,  the  symptoms  of  tetanus,  which  proves 
fatal  after  a  few  days,  develop,  and  the  spore-bearing  bacilli  can  then 
be  demonstrated  microscopically  in  the  wound  secretion  and  can  be 
obtained  in  pure  cultures. 

Tetanus  a  Wound  Infection. — Tetanus  is  essentially  a  wound  infec- 
tion, even  if  clinicians  are  accustomed  to  differentiate  a  traumatic  teta- 
nus (with  a  demonstrable  infection  atrium)  from  a  rheumatic  or  idio- 
pathic tetanus  (without  a  demonstrable  infection  atrium).  Any  injury 
of  the  epithelium  of  the  skin  or  mucous  membrane,  however  insignificant, 
may  be  followed  by  tetanus.  Frequently  the  wounds  Avhich  are  followed 
by  the  disease  are  those  in  which  the  tissues  are  lacerated  and  contami- 
nated with  earth.  It  follows  most  frequently  compound  fractures,  in- 
juries produced  by  the  explosion  of  a  bomb,  or  by  penetrating  foreign 
bodies  (for  example,  a  splinter  of  wood)  ;  more  rarely  gangrenous 
wounds,  scratched  acne  pustules,  insect  bites,  and  the  wound  resulting 
from  the  separation  of  the  cord  in  the  newborn  (tetanus  neonatorum). 
It  sometimes  follows  lesions  of  the  inner  surface  of  the  uterus,  as  in 
puerperal  tetanus,  and  injuries  of  the  epithelium  of  the  mucous  mem- 
brane of  the  nose  and  pharynx  (supposedly  in  idiopathic  tetanus). 

Characteristics  of  Wounds  Favoring  Development  of  Tetanus  Ba- 
cillus.— It  is  remarkable,  considering  the  wide  distribution  and  resist- 
ance of  the  bacilli,  which  have  remained  virulent  for  eleven  years  on 
a  splinter  of  wood,  that  the  disease  is  so  rare.  As  a  rule,  the  infection 
of  the  wound  with  tetanus  bacilli  is  not  alone  enough  to  cause  the  dis- 
ease. The  bacillus  demands  special  conditions  for  its  development. 
Saprophytic  organisms,  usually  found  in  wounds  contaminated  with 
earth  or  foreign  bodies,  favor  the  development  of  the  bacilli,  which, 
as  a  rule,  are  easily  destroyed  by  the  bactericidal  substances  in  the  tis- 
sue fluids.  Severe  injuries  to  the  tissues  (lacerations  and  contusions), 
which  are  followed  by  necrosis  and  putrefactive  changes,  also  favor  the 
growth  of  the  bacilli.  ["  Necrotic  tissue  favors  the  proliferation  of 
tetanus  bacilli  in  two  ways.  In  the  first  place,  it  seals  up  the  wound 
to  a  certain  extent,  and  thus  provides  the  requisite  anaerobic  condition; 
in  the  second  place,  it  would  seem  to  prevent  phagocytosis  of  the  bacilli 
in  some  obscure  way.  It  has  been  suggested  that  the  strong  chemotactic; 
relation  which  exists  between  necrotic  material  and  leucocytes  causes 
the  latter  to  take  up  dead  tissue  rather  than  bacilli.     That  innocent 


338  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

foreign  material  may  favor  the  development  of  tetanus  was  shown  by 
Vaillard  and  Rouget.  They  demonstrated  that  tetanus  would  develop 
in  the  presence  of  an  artificially  produced  ha?matoma  or  a  subcutaneous 
fracture,  while  in  the  absence  of  such  predisposing  factors  the  bacilli 
were  taken  up  by  phagocytes." — Ricketts,  "  Infection,  Innnunity,  and 
Serum  Therapy,"  pp.  247  and  248.]  Rational  wound  treatment  (open 
treatment  and  drainage)  often  prevents  the  development  of  those  con- 
ditions which  favor  the  growth  of  the  bacilli  and  the  later  development 
of  the  disease. 

Epidemics  of  Tetanus. — Epidemics  of  tetanus  have  been  observed  in 
wars.  These  epidemics  are  easily  explained,  as  all  the  important  fac- 
tors (severe  injuries,  contamination  of  the  wound  with  street  dirt  or 
earth)  which  favored  the  infection  of  the  wound  and  growth  of  the 
bacilli  were  present. 

Post-operative  tetanus,  which  often  became  endemic  in  earlier  times, 
is  only  occasionally  seen  by  the  surgeon  at  the  present  time.  In  these 
cases  the  wounds  are  infected  by  soiled  dressings,  unclean  instruments, 
etc.  Tetanus  has  occasionally  developed  after  gynecological  operations 
(Koch,  Phillips). 

Tetanus  bacilli  rarely  extend  beyond  the  primary  wound.  They 
have  been  demonstrated  in  the  neighboring  lymphatic  nodes  (Schnitzler), 
in  the  viscera  (Creite),  in  the  circulating  blood  (Hochsinger),  and  in 
the  blood  taken  from  cadavers   (Ilohlbeck). 

Incubation  Period  of  Tetanus. — The  incubation  period  in  man  varies 
from  twenty-four  hours  to  sixty  days.  As  a  rule,  the  disease  develops 
between  the  eighth  and  fourteenth  days.  Tetanus  has  developed  in  four 
days  after  an  accidental  infection  with  a  pure  culture  of  the  bacilli. 
["In  the  statistics  of  Rose,  twenty  j^er  cent  of  the  cases  showed  symp- 
toms in  the  first  week,  forty-five  per  cent  in  the  second,  and  about  thirty 
per  cent  in  the  third  or  fourth  weeks." — Ricketts,  "  Infection,  Im- 
munity, and  Serum  Therapy,"  p.  249.]  A  certain  time  is  required  for 
the  development  of  the  bacteria  and  their  toxins  before  they  are  ab- 
sorbed and  act  upon  the  nervous  tissues. 

Condition  of  Infected  Wounds. — There  are  no  changes  in  the  wound 
which  are  characteristic  of  an  infection  with  tetanus  bacilli.  The 
wound  may  be  suppurating,  granulating,  or  healed  when  the  first  symp- 
toms of  the  disease  develop.  Frequently  foreign  bodies  on  which  the 
bacilli  have  gradually  develoi)ed  are  found  in  the  cicatrix. 

Symptoms  and  Clinical  Cause.- — The  chief  symptoms  of  tetanus  are 
Ictanic  muscular  contractions  accompanied  by  chmic  spasms  of  greater 
or  less  degree,  recurring  at  varying  int(>rvals.  The  nniscular  contrac- 
tion is  most  pronounced  in  the  muscles  of  mastication,  and  causes  the 
painful  "  lock-jaw,"  the  so-called  trismus.     More  rarely  the  contrac- 


TETANUS:   LOCKJAW  339 

tion  begins  in  the  muscles  about  the  wound  and  then  extends,  so  that 
later  almost  the  entire  nmsculature  is  involved.  A  high  J'cver  may  be 
present  from  the  beginninu',  or  may  develop  later  during  tlif  last  hours 
or  days  of  the  disease.  Fever  may  be  absent  in  tlie  fatal  cases  as  well 
as  in  the  eases  which  recover. 

Tetanus  pursues  an  acute  or  chronic  course,  depending  upon  the 
severity  of  the  symptoms. 

In  the  acute  form,  spasms  of  the  muscles  of  the  neck  and  face  de- 
velop soon  after  the  trismus.  Then  the  muscles  of  the  back,  abdomiiuil 
wall,  and  extremities  become  involved  in  fre(}uently  recurring  clonic 
spasms.  Unless  the  local  spasms  begin  in  the  nniscles  of  the  arms,  the 
latter  are  either  spared  or  but  little  involved.  Contraction  of  the  mus- 
cles of  the  face  gives  the  patient  a  characteristic  grinning  expression 
(risus  sardonicus)  and  a  senile  appearance  (facies  tetanica)  due  to  the 
wrinkling  of  the  skin  of  the  forehead  and  cheeks. 

The  painful  muscular  spasms,  mostly  tonic  in  character,  may  finally 
involve  practically  all  the  nniscles  of  the  body.  These  spasms,  recur- 
ring at  irregular  intervals  and  lasting  for  dilferent  lengtlis  oi"  time,  are 
often  produced  by  the  slightest  irritation,  such  as  touching  the  patient 
or  by  some  noise,  and  so  disturb  him  that  sleep  and  the  taking  of  food 
are  rendered  impossible.  The  attempt  to  .SA\'allow  may  bring  on  a  con- 
vulsion, as  the  reflex  excitability  is  so  increased. 

Bathed  in  sweat,  with  anxious  expression  and  grinning  mouth  and 
with  teeth  pressed  firmly  against  one  another,  the  unfortunate  patient 
awaits  these  frightful  convulsions,  which,  if  the  extensor  nniscles  of  the 
back  are  involved,  often  force  the  head  far  back  into  the  ])illow  (opis- 
thotonos). The  discharge  of  faeces  and  urine  may  be  rendered  dif- 
ficult or  impossible  by  the  contraction  of  the  sphincter  muscles.  If  the 
nniscles  of  respiration  are  involved,  death  from  suffocation  may  occur 
twenty-four  hours  after  the  trismus.  Spasm  of  the  glottis,  cardiac  pa- 
ralysis, and  aspiration  pneumonia  may  cause  death.  Shortl.v  before 
death  the  temperature,  which  may  be  very  high  (1()!)°-110'-  F.),  falls. 
These  excessively  high  temperatures  are  i)ai'tly  due  to  nnisciilar  action. 

Prognosis. — ]\lost  frequently  these  iwutv  ca.ses  terminate  fatally 
within  the  first  four  days.  Each  day  which  the  patient  survives  gives 
a  better  prognosis,  for  usually  after  a  week  the  convulsions  become  less 
frequent  and  less  severe,  some  groui)s  of  muscles  lose  their  rigidity  and 
are  spared  when  subsequent  spasms  i-ecur.  The  earlier  the  symi)toms  of 
tetanus  develop  after  an  injury,  the  more  fi^ecjuently  the  spasms  recur 
and  the  more  extensive  the  muscle  grou])s  involved,  the  graver  the 
prognosis.  ["  In  man,  as  in  animals,  it  is  found  that  the  shorter  the 
incubation  period,  the  more  severe  the  disease  and  the  worse  the  prog- 
nosis.    It  is  stated  that  of  those  cases  where  the  incubation  period  is 


340  WOUND   INFECTIONS   OF   DIFFERENT   ORKJINS 

under  ten  days,  not  more  than  3  to  4.5  per  cent  recover;  when  the  incu- 
bation period  is  from  eleven  to  fifteen  days,  25  per  cent  recover;  in 
those  cases  in  which  the  incubation  period  is  still  longer,  about  half 
the  patients  attacked  throw  off  the  disease.  Different  authors  give  dif- 
ferent statistics,  but  these  are  the  general  results." — T.  C.  Allbutt, 
*'  System  of  Medicine,"  p.  773.]  If  acute  symptoms  do  not  develop 
again  and  if  no  complications,  such  as  aspiration  pneumonia,  occur 
after  improvement  begins,  the  patient  may  slowly  recover.  Disappear- 
ance of  the  trismus  and  lessened  excretion  of  sweat  are  indications  of 
recovery,  but  both  are  unreliable. 

In  chronic  forms  this  severe  clinical  picture  is  not  seen.  The  mus- 
cles of  respiraticm  are  not  involved,  and  but  little  fever,  or  none  at  all, 
accompanies  the  difficulty  in  s\\allowing,  the  trismus,  and  the  rigidity 
of  the  muscles  of  the  neck.  These  may  be  the  only  symptoms.  Recov- 
ery may  occur  after  a  week,  at  latest  after  three  months. 

Diagnosis. — The  diagnosis,  when  the  symptoms  are  pronounced,  is 
easy.  If,  in  the  chronic  forms,  trismus  is  the  only  symptom  at  the 
beginning,  all  acute  diseases  of  the  mouth  and  pharynx  which  are 
associated  with  trismus  and  an  elevation  of  temperature  must  be 
excluded. 

Varieties  of  Tetanus. — Tetanus  hi  the  newhorn  (tetanus  neonatorum) 
develops  in  from  one  to  five  days  after  the  separation  of  the  cord.  The 
demonstration  of  bacilli  in  the  pus  discharged  from  the  suppurating 
navel  proves  conclusively  that  the  infection  occurs  here.  The  child  pre- 
sents the  ordinary  symptoms  of  the  disease.  The  way  in  which  the 
crying  child  releases  the  nipple,  which  Avas  eagerly  grasped,  is  rather 
striking.     In  most  cases  death  occurs  on  the  third  or  fourth  day. 

Puerperal  Tetanus. — In  puei'peral  tetanus  (tetanus  puerperalis)  the 
infection  is  introduced  by  filthy  midwives,  often  in  performing  abor- 
tions. The  uterine  nuicous  membrane  affords  the  infection  atrium  for 
th(!  bacilli  which  have  been  demonstrated  in  these  cases.  This  form  of 
tetanus  is  s(!vere  and  ends  fatally. 

Head  Tetanus. — Head  tetanus  (tetanus  eephalicus)  follows  injuries 
in  the  area  of  distril)ution  of  one  of  the  cranial  nerves.  The  disease  has 
received  a  number  of  names,  selected  because  of  its  principal  symptoms. 
In  the  acute  severe  forms  pharyngeal  and  laryngeal  spasms,  the  result 
of  increased  i-eflex  excitability,  soon  develop.  These  resemble  the  spasms 
occurring  in  hydrophobia,  and  for  this  reason  the  disease  has  been 
called  letanus  liyelrophobicus  by  Rose.  It  is  characterized  by  tetanic 
contractions  of  the  muscles  of  mastication,  combined  with  a  paralysis  of 
some  of  the  muscles  supplied  by  cranial  nerves,  particularly  of  those 
supplied  by  the  facial  nerve  (therefore  tetanus  facialis  according  to 
Rose,  or  tetanus  parahjtieus  according  to  Klennn).     The  I'igidity  then 


TETANUS:    LOCKJAW  341 

extends  to  the  muscles  of  the  neck,  trunk,  and  extremities.  Death  is 
produced  by  sutt'ocation  during  a  convulsion,  or  by  cardiac  paralysis. 

In  the  subacute  and  chronic  cases  the  symptoms  are  often  mild,  and 
may  be  limited  to  the  region  supplied  by  cranial  nerves.  According  to 
Brunner,  in  some  cases  a  tonic  contraction  of  the  nniscles  supplied  by 
the  facial  nerve  develops  first  upon  the  side  of  the  injury,  or,  if  the 
injury  is  in  the  median  line,  upon  both  sides;  then  follow  immediately 
spasms  of  the  muscles  of  mastication.  In  other  cases,  however,  the 
muscles  supplied  by  the  facial  nerve  become  paralyzed  first  upon  the 
side  of  the  injury,  and  spasms  of  the  muscles  of  mastication  then  de- 
velop. It  is  remarkable  that  the  paralysis  never  involves  the  motor 
branch  of  the  fifth  cranial  nerve.  Paralysis  of  the  third  and  fourth 
cranial  nerves  has  been  noted  when  the  injury  involved  the  eye.  As  a 
rule,  fever  does  not  accompany  head  tetanus.  Apparently  the  toxin 
extends  along  the  nerves,  injures  the  nuclei,  and  produces  paralj^sis  in 
this  way. 

Treatment. — In  discussing  the  treatment  of  tetanus,  serum  therapy 
must  be  considered  first.  It  is  impossible  to  understand  the  action  of 
antitetanic  serum  without  a  clear  idea  of  the  action  of  tetanus  toxin, 
and  therefore  the  mode  of  action  of  the  latter  will  be  briefly  dis- 
cussed. 

After  an  incubation  period  varying  with  the  animal  used,  a  fatal 
disease  follows  subcutaneous  and  intravenous  injections  of  tetanus 
toxins.  It  has  been  determined  by  experimental  work  that  the  toxins 
are  absorbed  from  the  wound  by  the  end  organs  of  motor  nerves,  and 
that  they  joass  along  the  axis  cylinders  to  the  central  nervous  system. 
The  toxins  also  circulate  in  the  blood,  from  which  they  disappear  when 
the  spasms  begin  (Blumenthal).  In  all  probability  these  toxins  are 
deposited  in  some  part  of  the  neuromuscular  apparatus.  It  has  been 
shown  that  the  toxins  act  upon  the  central  nervous  system,  especially 
upon  the  motor  centers  of  the  spinal  cord  and  medulla  oblongata.  The 
excitability  of  these  centers  is  increased  in  tetanus,  and  any  stinuilus 
provokes  a  violent  reaction.  The  results  of  the  following  experiments 
prove  concliLsively  that  the  toxin  does  not  act  upon  the  muscles,  the 
peripheral  nerves,  or  brain  (von  Leyden  and  Blumenthal)  :  (1)  When 
the  motor  nerves  are  cut  or  the  animal  is  curarized,  the  tetanic  mus- 
cular contraction  ceases;  (2)  when  the  cerebrum  is  removed,  tetanus 
can  still  be  produced  (Brunner)  ;  (3)  tetanic  contractions  do  not  de- 
velop in  nuLseles  when  the  corresponding  spinal  segments  are  destroyed. 

Pathological  Anatomy. — Microscopic  changes  in  the  motor  ganglion 

cells  have  been  described  by  Goldscheider.  Flatau,  and  others.     These 

changes  are  not  regarded  by  other  investigators  as  peculiar  to  tetanus. 

A.  Wassermaini  and  Takaki  have  shown  that  tetanus  toxin  has  a  strong 

23 


342  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

affinity  for  nervous  tissue  containing-  substances  not  found  in  other 
organs  which  bind  the  tetanus  toxins.  If  a  mixture  of  tetanus  toxins 
and  brain  tissue  is  injected  into  guinea  pigs  or  rabl)its  the  animals  do 
not  develop  the  disease,  as  the  toxins  have  already  been  rendei'ed  inert 
by  their  union  with  the  nervous  tissue.  ["  It  is  hekl  by  certain  authors 
that  the  toxin  attacks  only  the  nervous  tissue  in  man ;  in  some  of  the 
lower  animals,  however,  various  organs,  especially  the  liver,  have  an 
affinity  for  the  toxin." — Ricketts,  "  Infection,  Immunity,  and  Serum 
Therapy,"  p.  250.] 

Absorption  of  Tetanus  Toxin. — It  has  been  demonstrated  by  the  ex- 
periments of  ]\Ie3'er  and  Ransom,  Tiberti,  and  others  that  the  toxins 
pass  along"  the  peripheral  (motor)  nerves  to  the  central  nervous  system. 
Local  contractions  which  are  not  frequent  in  man,  except  in  head  teta- 
nus, occur  in  animals  after  subcutaneous  (not  after  intravenous)  injec- 
tions. These  local  contractions  are  due  to  the  extension  of  the  toxins 
along  the  nerves  to  the  segments  corresponding  to  the  muscles  about  the 
wound  (Stinzing  and  others). 

Tetanus  Antitoxin. — If  an  animal  has  recovered  from  the  disease  it 
is  immune  against  small  doses  of  virulent  toxins  or  larger  doses  of  atten- 
uated toxins.  By  injecting  gradually  increasing  doses  of  the  toxins 
the  immunity  may  be  so  raised  that  the  animal  can  withstand  the  in- 
jections of  pure  tetanus  toxins  or  of  virulent  bacilli.  The  animal  has 
become  immune,  and,  according  to  Behring  and  Kitasato,  its  blood 
serum  has  the  power  to  neutralize  tetanus  toxin,  to  protect  other  ani- 
mals against  tetanus,  and  to  cure  them  when  the  disease  has  already 
developed.  The  bacilli  are  not  killed  by  the  antitoxin,  but  they  are 
no  longer  active,  as  their  toxin  is  rendered  harmless.  The  blood  serum 
of  imnumized  horses  (antitoxin)  affords  a  certain  protection  to  man 
when  used  in  the  treatment  of  tetanus. 

According  to  our  present  knowledge,  a  concentrated  antitoxin  is 
able  to  neuti-alize  the  tetanus  toxin  circulating  in  the  blood,  and  if  the 
organism  is  not  flooded  with  large  quantities  of  the  toxin,  one  may 
hope  by  rep(\ated  injections  not  only  to  neutralize  the  toxin  in  the 
blood,  but  also  to  render  harmless  the  toxins  continually  absorbed  from 
the  wound,  before  they  can  act  upon  the  ganglion  cells  in  the  spinal 
cord  and  medulla.  As  soon  as  the  toxin  becomes  united  with  the  gan- 
glion cells,  the  antitoxin  circulating  in  the  blood  no  longer  has  any 
effect,  as  it  either  reaches  the  spinal  cord  in  too  small  amounts  or  is 
unable  to  break  up  the  chemical  union  between  the  toxin  and  the  gan- 
glion cell.  Attempts  have  been  made  to  bring  the  serum  into  direct  con- 
tact with  the  centrid  nervous  system  and  the  centers  upon  which  the 
toxin.s  act.  Jacob  has  injected  the  serum  into  the  subdural  space, 
Koclicr  into  the  ventricles  of  the  bi'ain.     Experimental  work  indicates 


TETANUS:    LOCKJAW  343 

that  direct  injection  is  of  some  value.  No  definite  conclusions  can  be 
drawn  from  clinical  experience. 

Antitoxin  should  be  injected  as  soon  as  possible  after  the  first  symp- 
toms of  the  disease  develop  (according  to  von  Behring  within  the  first 
thirty  hours),  and  a  subcutaneous  or  intravenous  injection  of  a  certain 
amount  should  be  made  daily.  Unpleasant  symptoms  follow  the  intra- 
venous injections  of  some  sera,  and  for  that  reason  von  Behring  recom- 
mends that  subcutaneous  injections  should  be  made,  preferably  in  the 
area  surrounding  the  wound.  In  tetanus  puerperalis  the  serum  should 
be  injected  into  the  vagina,  in  tetanus  neonatorum  into  the  al)dominal 
cavity.  Calmette  reconnnends  that  the  dried  serum  be  sprinkled  on  the 
wound.  Kiister  has  exposed  the  nerves  supplying  the  region  of  the 
wound  and  has  injected  the  serum  into  them.  This  treatment  has  ap- 
parently been  successful  in  some  cases. 

[Antitetanic  serums  are  not  standardized  by  American  manufac- 
turers, and  it  is  impossible  to  control  accurately  the  dosage.  Not  less 
than  10  c.c.  should  be  given  for  prophylactic  purposes,  and  this  dose 
should  be  repeated.  It  is  impossible  to  set  any  definite  limits  for  the 
amounts  which  should  be  used  for  curative  purposes.  As  previously 
mentioned  the  curative  action  of  the  serum  cannot  be  relied  upon.  It 
is  most  useful  as  a  prophylactic,  and  should  be  given  in  all  cases  in 
which  there  is  a  possibility  that  tetanus  may  develop.] 

Technic  for  Injection  of  Serum  into  tlte  Lateral  Ventricle  and  tJte 
Spinal  Subdural  Space. — In  Kocher's  method  of  injecting  into  the  lateral 
ventricle  a  small  trephine  ojiening  is  made  in  the  skull  from  1  to  1:^ 
inches  lateral  to  the  bregma,  the  point  at  which  the  sagittal  and  coronal 
sutures  meet.  A  long  needle  is  then  passed.  2  or  2-|  inches  into  tlic  l)i'ain 
substance  in  a  vertical  direction.  When  fluid  flows  from  the  needle, 
the  serum  is  injected  slowly.  Tavel  makes  the  opening  1}  inches  from 
the  median  line  and  1\  anterior  to  the  conmal  sutui'es.  lie  tbrii  passes 
the  needle  toward  the  foramen  nuignum.  The  lateral  ventricle  may  also 
be  reached  froni  the  frontal  region,  from  just  above  and  a  little  to  the 
inner  side  of  the  frontal  eminence  (von  Bergraann),  from  the  lateral 
surface  of  the  skull  (Keen),  and  from  the  occipital  regicm  (Beck).  It 
is  best  to  make  a  skin  periosteal  flap  in  exposing  the  an-a  in  which  the 
opening  is  to  be  made.  The  flap  can  then  be  sutured  in  position  and 
subsequent  injections  made  through  it  (Tavel).  The  danger  of  infec- 
tion is  lessened  by  this  procedure. 

The  technic  employed  in  Quincke's  lumbar  puncture  is  used  in  mak- 
ing spinal  injections.  The  patient  is  placed  upon  his  left  sid(>  and  a 
needle  is  passed  between  the  spines  of  the  tliird  and  foui'tli  lum])ar  verte- 
bra', and  is  forced  forwai'd  somewhat  upward  ami  inward.  Ai'tei-  con- 
siderable cerebro-spinal  fluid  has  escaped,  the  serum  is  injected  slowly. 


344  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

Results  of  Serum  Treatment. — It  is  difficult  to  judge  of  the  value 
of  the  serum  treatment  in  mild  cases,  as  a  large  proportion  of  these 
recover  spontaneously.  On  the  other  hand,  in  the  severe  cases,  which 
usually  develop  within  a  week  after  the  injury,  the  serum  has  no  cura- 
tive action,  although  it  has  been  demonstrated  that  it  passes  through 
the  body,  as  it  has  been  found  in  the  urine  (von  Leyden). 

As  the  serum  treatment  cannot  be  relied  upon  when  the  disease  has 
developed,  it  is  the  duty  of  the  attending  physician  to  try  any  treat- 
ment which  may  possibly  cure  the  disease  or  at  least  alleviate  the 
suffering. 

Treatment  of  the  Wound. — Toxins  are  being  continually  absorbed 
from  the  wound,  and  this  should  be  prevented.  When  the  position  and 
form  of  the  wound  permits,  as  in  the  fingers  or  toes,  an  amputation 
or  a  thorough  excision  should  be  performed.  In  extensive  and  compli- 
cated injuries  of  the  extremities,  particularly  in  compound  fractures, 
amputation  is  indicated  as  soon  as  the  first  symptoms  develop.  Only  in 
the  mildest  cases  should  this  indication  be  disregarded.  All  necrotic 
tissue  and  blood  clots  should  be  removed  from  the  large  wounds  of  the 
trunk,  and  the  undermined  soft  tissues  should  be  opened  widely  in 
order  to  prevent  putrefaction,  Avhich,  according  to  experimental  work, 
increases  the  virulence  of  the  bacilli.  The  aseptic,  open  treatment  of 
the  wound  is  an  important  preventive  measure,  as  it  permits  of  the  free 
access  of  air  which  prevents  the  growth  of  anaerobic  bacilli.  Foreign 
bodies,  lying  in  the  wound  or  encapsulated  in  the  scar,  should  be  re- 
moved, as  large  numbers  of  bacilli  are  usually  attached  to  them. 

Cauterization  of  the  wound,  which  is  frequently  recommended  by 
physicians,  does  harm,  as  the  eschar  which  forms  prevents  the  discharge 
of  wound  secretion.  If  the  wound  is  contaminated  with  street  dust, 
manure,  or  earth,  or  has  been  received  in  localities  where  tetanus  is  of 
frequent  occurrence,  a  prophylactic  injection  of  serum  should  be  given, 
and  if  practicable  the  wound  should  be  excised.  In  spite  of  such  proph- 
ylactic injections,  tetanus  may  develop  and  end  fatally,  even  if  the 
majority  of  cases  handled  in  this  way  recover  (Suter). 

The  remaining  treatment  is  purely  symptomatic.  Narcotics  should 
be  given  to  control  the  spasms,  especially  the  dangerous  spasms  of  the 
nuiscles  of  respiration.  Large  doses  of  morphin  and  chloral  act  best. 
In  feeding  the  patient,  the  dangers  of  aspiration  pneumonia  should  be 
kept  in  mind.  Kectal  feeding  is  indicated  as  long  as  the  trismus 
and  pharyngeal  spasms  persist.  Any  exterii;il  ii-i-itation  will  cause 
convulsions  and  the  patient  must  Im'  placed  in  ((uiet  surroundings. 
Moi'pliin  should  be  given  before  the  divssiugs  ai'e  changed  or  the  pa- 
tient is  catheteri/ed.  Stinmlants  should  be  given  as  the  heart  becomes 
weak. 


DIPHTHERIA  345 

Literature. — 1\  Bchring  und  Kitasato.  Ueber  das  Zustandekommen  der  Diphtherie 
un.I  (ler  Tetanusiminunitat  bei  Tiereu.  Deutsche  nied.  ^^'(K■ll(■n.s(•hI•.,  ISOD,  j).  ill.*}. — 
Bcnjell  und  Levy.  Ueber  den  Einfluss  de.s  Curare  bei  Tetanus.  Therapie  der  (Jegenwart, 
l'J04,  p.  396. — Brunner.  Kopftetanus.  Beitr.  z.  klin.  Chir.,  Bd.  9,  10  u.  12. — Calmette. 
Sur  I'absorption  de  I'antitoxin  tetanique  par  Ics  plaies.  Academic  dcs  sciences,  Mai, 
1903. — Creite.  Zuni  Nachweis  von  Tetanusbazillen  in  Organen  des  Menschen.  Cen- 
tralbl.  f.  Bakteriol.,  Bd.  37,  Orig.,  l'.)04,  p.  312.— Hohlbeck.  Vorkommen  des  Tetanus- 
bazillus  ausserhaib  der  Infektionsstelle  beim  Menschen.  Deutsche  med.  Wochenschr., 
1903,  p.  172. — Kitasato.  Ueber  den  Tetanusbazillus.  Zeitschr.  f.  Hygiene,  Bd.  7, 
18S9,  p.  225. — E.  Koch.  Tetanus  nach  Bauchoperat.  Deutsche  Zeitschr.  f.  Chir.,  Bd. 
48,  1898,  p.  417. — Kruse,  in  Die  Mikroorganisnien  von  Fliigge,  1890,  Bd.  2. — Kiister. 
Ein  Fall  von  ortl.  Tetanus.  Antitoxineinspritzungen  in  die  Nervenstiinune.  Heilung. 
Chir.-Kongr.  Verhandl.,  lOO.i,  II,  p.  161. — Lever.  Zur  TetanusbehantUung.  Therapie. 
d.  Gegenwart,  1901,  Juni. — v.  Leyden  und  BlumenthaL  Der  Tetanus.  Spez.  Path.  u. 
Ther.  von  Nothnagel,  V.  Bd.,  1900. — v.  Lingelsheini.  Tetanus.  In  Kolle-Wassermanns' 
Handb.  d.  pathog.  Mikroorganisnien,  Bd.  2,  1903,  p.  566,  with  Lit. — Marx.  L'eber  die 
Tetanusgift  neutralisierende  Eigenschaft  des  Gehirnes.  Zeitschr.  f.  Hygiene  u.  Inf., 
Bd.  40,  1902,  p.  231. — Meyer  und  Ransom.  Untersuch.  iiber  d.  Tetanus.  Arch.  f. 
experim.  Pathol.,  Bd.  49,  1903,  Part  6. — Neumann.  Der  Kopftetanus.  Kritisches 
Sammelreferat.  Centralbl.  f.  Grenzgeb.,  Bd.  5,  1902,  p.  503. — Nicolaier.  Ueber 
infektiosen  Tetanus.  Deutsche  med.  Wochenschr.,  1884,  p.  842. — Philips.  Tetanus  as 
a  Complication  of  Ovariotomy.  The  Lancet,  1892,  p.  139. — Rose.  Trismus  und  Tetanus. 
Deutsche  Chir. — Rosenbach.  Zur  Aetiologie  des  Wundstarrkrampfes.  Arch.  f.  klin. 
Chir.,  Bd.  34,  1886,  p.  306. — Steuer.  Sammelreferat  iiber  die  Therapie  des  Tetanus. 
Centralbl.  f.  Grenzgeb.,  1900,  Bd.  3. — Stinzing.  Beitrag  zur  Lehre  des  Tetanus  trau- 
maticus.  Grenzgeb.  d.  Med.  u.  Chir.,  1898,  Bd.  3  und  Miinch.  med.  Wochenschr., 
1898,  p.  1265. — Suter.  Zur  Serumbehandlung  des  Starrkrampfes,  insbes.  iiber  Tetanuser- 
krankungen  trotz  prophylaktischer  Serumtherapie.  Arch.  f.  klin.  Chir.,  Bd.  75,  1905, 
p.  113. — Tiberti.  Ueber  den  Transpert  des  Tetanusgiftes  zu  den  Riickenmarkszentren 
durch  die  Nervenfasern.  Centralbl.  f.  Bakteriol.,  Bd.  38,  Orig.,  1905,  p.  413. — v.  Torock. 
Experim.     Beitriige  zur  Therapie  des  Tetanus.     Zeitschr.  f.  Heilkunde,  1900,  Bd.  21. 


CHAPTER    IV 

DIPHTHERIA 

The  so-called  diphtheritic  inflammation  of  the  skin  and  mnoon-s 
membranes  is  a  fibrinous  inflannnation  associated  with  extensive  neei'o- 
sis.  This  particular  form  of  intiammation,  sonietimes  superficial  and 
sometimes  deep,  is  not  caused  by  diphtliei'ia  bacilli  only.  Typhoid  and 
dysentery  bacilli,  streptococci  and  chemicals  (aiinnonia)  produce  simi- 
lar changes  in  nnicous  membranes.  Diphtheria  bacilli  are  the  cause  of 
the  epidennc  infectious  disease  called  diphtheria  in  which  the  mucous 
membranes,  especially  those  of  the  upi)er  part  of  the  respiratory  and 
alimentary  tracts,  are  inflamed.  Streptococci  and  staphylococci  are  fre- 
quently associated  with  the  diphtheria  bacilli  in  fhese  cases,  or  they 
alone  may  produce  a  fibrinous  inflammation  and  necrosis  of  the  mucous 


346  WOUND   INFECTIONS  OF   DIFFERENT  ORIGINS 

membranes,  such  as  frequently  occur  in  scarlet  fever  (diphtheroid  scar- 
latina ) . 

Bacillus  of  Diphtheria. — Diphtheria  bacilli,  which  were  first  ob- 
tained in  pure  cultures  by  Loffler  (1884),  are  to  be  regarded  as  the  cause 

_^  of    epidemic    diphtheria,    and    occa- 

y^^*^'^       '^'^    x!^\  -  sionally  of  wound  diphtheria.     They 

^;^^  "'/'^  •'^I'e  slender,  often  S(Mnewhat  curved, 

/  --     C''?  rods,  usually  lying  irregularly  scat- 

>i  ^^  '^  *-     \     tered,   frequently   in   clusters.      The 

'  .  'o     '  ^^  '  '/    /  1    bacilli  are  not  motile,  are  about  as 

^  v^i     '"V  <s*     js      '         "^"'"^^       \    ^^^S   as    the   tubercle   bacillus    and 

Ax>%5^-^     "^  '  ■*  V  1  I    slightly  broader.     Often  one  end  is 

■  W^S   ^^       *"  r  ^        "         '  J    thickened,    but    they    do    not    form 

J-.vJ'S*;^^?  ,-jfV  /     spores.     They  are  found  in  the  mem- 

\          ^*'t'avf^*'s  -  ^^       3  •         /        branes  covering  mucous  surfaces,  in 
\         >     ^"'jv-^  /  ■  -,   ■ 

\       '*»,  -^      X  pneumonic    foci    in    patients    dying 

"-v^^^-,^     '^  V    •  T--^  of  diphtheria,   and  have   also   been 

,_^~~  ,,  demonstrated  in  the  adjacent  lymph 

Fig.  135. — Dh'iitukuia  Bacilli. 

nodes,  in  the  blood  of  cadavers,  in 
the  pus  from  submucous  phlegmons,  and  in  metastatic  abscesses  and  in 
wounds. 

They  stain  with  Loffler 's  alkaline  methylene-blue  solution,  Ziehl's 
carbol-fuchsin,  and  with  Gram's  method. 

They  grow  best  upon  Loffler 's  solidified  blood  serum,  also  upon 
glycerin-agar,  Avith  free  access  of  air.  Pinhead  size,  whitish  gray, 
opaque  colonies  appear  after  twenty-four  hours.  The  borders  of  the 
colonies,  when  viewed  under  a  glass,  are  irregular  and  slightly  granular, 
and  may  readily  be  distinguished  from  the  small  and  transparent  col- 
onies of  streptococci  growing  near  by.  In  bouillon  they  form  small 
granules,  which  become  attached  to  the  test  tube. 

For  diagnostic  purposes  a  piece  of  the  membrane  should  be  re- 
moved with  sterile  forceps,  washed  in  sterile  water  to  remove  the  bac- 
teria of  the  numth,  and  a  number  of  stroke  cultures  made  upon  slant 
media.  After  ten  hours  at  the  earliest,  grayish  yellow  streaks  appear 
upon  the  sui'fjice,  from  which  microscopic  preparations  may  be  made. 
The  l);i('illi  sliould  be  stniiicd  accor-ding  to  (Jram's  method.  Animal 
experiments  should  also  be  made  to  prevent  mistaking  them  for  the 
non-pathogenic  jyscudo-diphlhcria  bacilli,  similar  in  appearance  and 
found  in  the  iiioulli. 

Guinea  pigs  are  best  suited  for  experimental  purposes;  usually  0.5 
e.c.  of  a  twenty-four-hour  old  bouillon  culture  will  kill  these  animals. 
Rabbits,  sheep,  young  dogs,  cattle,  horses,  hens,  pigeons,  and  eats  are 
susceptible;   mice  and    lats  ai-e  not.     vXfter  subcutaneous   inj(>ctions  of 


DIPHTHERIA  347 

cultures,  animals  die  in  twenty-four  hours  or  in  from  one  to  two  weeks, 
depending  upon  the  virulenee  of  the  baetei'ia  and  the  number  injected. 

(Edema  about  the  point  of  injection,  pk'ural  exudates,  and  fatty 
degeneration  of  the  viscera  are  found  when  a  i)ost-mortem  examination 
is  made.  Paralyses  have  been  observed.  Infections  of  the  mucous  mem- 
brane produce  an  inflammation  associated  with  necrosis. 

Subcutaneous  injections  of  filtered  ])acteria-free  cultures  produce 
the  same  results,  as  they  contain  the  poisonous  metal)olic  product  (tox- 
ins) of  the  bacilli.  Diphtheria  bacilli  are  therefore,  like  tetanus  bacilli, 
toxic  bacteria.  Tlie  infection  is  primarily  a  local  one,  and  the  general 
symptoms  are  produced  by  the  absorption  of  the  toxins.  Only  rarely 
do  the  bacilli  pass  beyond  the  primary  focus  of  infection. 

According  to  the  investigations  of  Brieger  and  C.  Friinkel,  diph- 
theria toxin  should  be  regarded  as  a  toxa]l)umin ;  but  wlien  pure  it 
does  not  respond  to  the  tests  employed  for  either  albumins  or  i)eptones 
(Brieger  and  Boer).  Optically,  it  is  inactive  and  cannot  be  placed  in 
any  of  the  groups  known  to  organic  chemistry   (Beck). 

Diphtheria  Antitoxin. — The  blood  serum  of  experimental  animals 
immunized  against  diphtheria  protects  other  animals  from  infection 
and  cures  those  in  which  the  symptoms  have  already  developed  (von 
Behring  and  AVernieke).  It  contains  an  antitoxin.  Diphtheria  bacilli, 
like  tetanus  bacilli,  are  not  killed  by  the  antitoxin,  but  their  toxins  are 
neutralized  and  the  bacilli  gradually  disappear  from  the  body.  The 
blood  serum  of  patients  who  have  recovered  from  the  disease  has  for  a 
short  time  the  power  of  immunizing  aninuils  (Klemensiewicz  and  Es- 
cherich,  Abel). 

The  serum  used  in  the  treatment  of  the  disease  is  obtained  almost 
exclusively  from  horses   (von  Behring)    (ride  Treatment). 

Modes  of  Infection  and  Susceptibility. — Infection  in  man  foUows 
direct  or  indirect  transference  of  the  bacilli  from  a  patient.  Direct 
infection  may  follow  kissing,  coughing,  and  sneezing.  InfV'ction  nuiy  be 
carried  by  any  object,  especially  eating  utensils  and  handkerchiefs 
which  have  come  in  contact  with  the  patient's  mouth  or  the  secretions 
from  his  mouth  and  nose.  Diphtheria  bacilli  may  cause  a  febrile  angina 
without  a  membrane.  Convalescent  patients,  and  even  healthy  people 
who  have  been  about  diphtheria  patients,  harbor  bacilli  in  Iheir  mouths, 
and  so  it  is  possible  for  the  disease  to  be  transferred  by  people  who  are 
not  sick.  The  patient's  excreta  are  especially  dangerous,  as  the  bacilli 
remain  viable  from  three  to  four  months  in  the  dried  condition;  for 
example,  in  the  expectorated  and  dried  membrane. 

All  people  are  not,  however,  susceptible  to  the  disease,  ("hildi-en 
from  two  to  foiu-  years  of  age  are  most,  adults  least,  susceptible. 
Among  adults  innnune  persons  are  found  whose  blood  serum  has  a  pro- 


348  AVOUND    INFECTIONS   OF    DIFFERENT   ORIGINS 

tective  action,  although  they  have  never  had  the  disease  (Abel,  Wasser- 
mann).  Diseases  of  the  raucous  membranes,  chronic  catarrh  and  an- 
gina, such  as  occur  in  measles  and  scarlet  fever,  favor  the  development 
of  diphtheria.  An  immunity,  which  lasts  for  a  short  time,  follows  the 
disease. 

It  is  doubtful  whether  the  disease  is  transferred  from  animals  to 
man. 

DIPHTHERIA   OF  MUCOUS  MEMBRANES 

Loffler's  bacillus,  usually  associated  with  other  bacteria,  produces 
an  inflammation  which  involves  most  frequently  first  the  mucous  mem- 
brane covering  the  tonsils,  the  pillars  of  the  fauces,  and  the  pharynx; 
and  which  then  may  extend  to  the  mucous  membranes  of  the  nose, 
larynx,  trachea,  and  finer  bronchi,  and  the  middle  ear.  Much  more 
rarely  the  inflammation  involves  primarily  the  mucous  membrane  of  the 
larynx  and  nose.  Primary  inflammation  of  the  mucous  membrane  of 
the  vagina  and  secondary  involvement  of  the  ojsophageal  and  gastric 
mucous  membranes  occur,  but  are  very  rare. 

Onset. — The  disease  begins  with  general  and  local  symptoms.  Often 
it  develops  suddenly  with  high  fever,  delirium,  etc. ;  often  slowly  with 
prostration,  chilly  feelings,  and  loss  of  appetite.  The  first  local  symp- 
toms naturally  depend  upon  the  location  of  the  infection.  Diphtheria 
of  the  pharynx  begins  with  pain  upon  swallowing;  of  the  larynx,  with 
hoarseness,  coughing,  and  dyspnoea;  of  the  nose,  with  a  profuse,  puru- 
lent, ha3morrhagic  discharge. 

At  first  the  infected  mucous  membrane  is  swollen,  glistening,  and 
reddish.  Soon  small,  whitish,  slightly  raised  patches  appear  (in  pha- 
ryngeal diphtheria  these  appear  upon  the  tonsils  first).  At  first  these 
patches  may  be  easily  removed,  as  they  are  composed  of  fibrin  only, 
which  is  deposited  upon  the  sloughing  epithelium.  These  patches  grad- 
ually extend  and  become  thicker  as  an  exudate  is  poured  out,  so  that, 
for  example,  in  pharyngeal  diphtheria  after  a  few  days  the  tonsils,  the 
pillars  of  the  fauces,  the  uvula,  and  the  entire  pharyngeal  wall  become 
covered  with  a  whitish  or  grayish  yellow  membrane.  The  inflamma- 
tion may  extend  deeper  and  involve  the  connective  tissues  of  the  mu- 
cous membrane,  then  these  become  infiltrated  and  necrotic. 

Pseudo-membrane. — In  the  beginning  of  the  disease  and  in  mild  cases 
tlie  pseudo-ineriibrane  is  but  loosely  attached  to  the  surface  of  the  epi- 
thelium. When  removed  only  the  epithelial  cells  are  tnken  with  it,  and 
healing  without  scar  formjition  mny  occnr  if  a  Jicw  iiiciiibrane  does  not 
form.  In  advanced  mid  severe  cnses  the  coimective  tissues  of  the  mu- 
cous ineiiibrMne  are  also  involved,  and  the  membrane  is  often  removed 
with   (linicnllv,   jukI    when    removed   leaves  bleeding  surfaces.     It  is  no 


DIPHTHERIA  349 

longer  correct  to  distinguish  in  epidemic  diphtheria  between  croupous 
and  diphtheritic  changes  or  between  croup  ^  and  diphtheria,-  for  they 
are  only  different  phases  of  the  same  local  pathological  processes.  As 
a  rule,  the  pseudo-membrane  is  more  closely  attached  to  S((uanious  than 
to  ciliated  epithelium,  as  in  the  former  there  is  no  basal  membrane  to 
prevent  its  attachment  to  the  underlying  connective  tissues. 

After  spontaneous  separation  of  the  pseudo-membrane,  the  mucous 
membrane  almost  always  heals  without  a  scar.  On  the  other  hand, 
when  the  pseudo-membrane  is  forcibly  removed,  another  membrane 
usually  forms  and  the  necrosis  extends  deeper.  Sears  form  in  the  ton- 
sils only  when  the  tissues  of  the  same  undergo  extensive  necrosis. 

Separation  of  Pseudo-membrane. — The  separation  of  the  membrane 
occurs  much  more  rapidly  in  adults  than  in  children.  In  the  former 
it  may  begin  after  the  first  day,  while  in  the  latter  after  the  first  week 
(Rumpf). 

Extension  the  Result  of  Secondary  Infection. — The  inflammation 
rarely  extends  to  the  cartilages  of  the  larynx  and  the  bones  of  the  nose. 
The  extension  in  the  severer  cases  is  due  to  secondary  infections  with 
other  bacteria  (putrefactive  or  pyogenic).  The  fibrinous  necrotic  areas 
then  undergo  putrefactive  changes  or  a  gangrene  of  the  entire  mucous 
membrane  develops.  An  extensive  cicatricial  stenosis  of  the  larynx 
may  follow  these  secondary  infections. 

In  diphtheria  infections  there  is  an  inflammatory  oedema  of  the 
submucous  tissues,  which  occasionally  ends  in  suppuration  (abscess, 
phlegmon).  Pyogenic  bacteria  are  important  factors  in  abscess  forma- 
tion, but  diphtheria  bacilli  alone  have  been  found  in  the  pus   (Tavel). 

The  adjacent  lymphatic  nodes  are  always  swollen  and  inflamed. 
Frequently  they  contain  small  grayish  white  necrotic  foci,  but  a])scesses 
rarely  develop. 

According  to  Frosch,  bacilli  may  be  much  more  frefjuently  demon- 
strated in  the  blood  and  viscera  than  was  formerly  considered  to  be 
the  case. 

Histology  of  Lesions. — INIicroscopieally  (Fig.  136)  there  is  found  in 
freshly  inflamed  areas  a  layer  of  fibrin,  the  fibers  of  which  are  arranged 
in  meshes  which  cover  the  degenerating  epithelium.  The  meshes  of  this 
fibrin   layer   contain   degenerated   epithelial  cells  and   leucocytes.      Its 


1  A  fibrinous  inflammation,  which  is  not  due  to  Loffler's  bacillus,  occurs  in  the 
pharynx  and  larynx  in  a  number  of  different  infectious  diseases,  such  as  the  acute 
exanthemata,  typhoid  fever,  whooping  cough,  and  pneumonia.  This  is  called  secon- 
dary croup,  or  better,  diphtheroid. 

2  The  term  diphtheritis  is  used  by  many  to  designate  the  local  changes  which  occur 
in  epidemic  diphtheria.  There  is,  however,  at  the  present  time,  no  uniformity  of  opinion 
concerning  the  use  of  this  term. 


350 


WOUND   INFECTIONS   OF   DIFFERENt   ORIGINS 


finer  fibers  extend  down  to  the  inflamed  and  infiltrated  tissues.  Older 
membranes  are  stratified,  the  oldest  and  most  superficial  layers  con- 
sisting of  layers  of  epithelial  cells  and  fibrin,  and  containing  large 
numbers  of  saprophytes.     Then  follows  a  fine-meshed  and  then  a  more 

_7  recent     coarse -meshed 

layer  of  fibrin.  The 
bacilli  are  usually 
found  in  the  first  layer, 
while  the  coarse-meshed 
layer  is  firmly  attached 
to  the  inflamed  and  in- 
filtrated connective  tis- 
sue. 

Clinical  Course  and 
Severity  of  the  Disease. 
— The  clinical  course  of 
the  disease  is  usually  so 
acute  that  recovery  or 
death  occurs  within  a 
week. 

The  severity  of  the 
disease  depends  upon 
the  character  of  the  epi- 
demic, the  position  and 
extension  of  the  inflam- 
mation, and  upon  mixed  infections.  Laryngeal  is  much  more  dangerous 
than  pharyngeal  diphtheria,  and  the  prognosis  is  very  unfavorable  if 
secondary  infection  with  other  bacteria,  especially  streptococci,  occurs. 
Prognosis. — The  mortality  is  especially  high  in  children.  Almost 
all  chihlren  in  the  first  year  of  life  die.  The  mortality  decreases  as  age 
advances. 

Causes  of  Death. — There  are  a  ninnber  of  causes  of  death,  depend- 
ing upon  the  local  course  of  the  disease,  the  general  toxic  infections, 
and  complicatioiir,. 

The  inflammation  of  the  mucous  membrane  alone  is  frequently  the 
cause  of  death  in  young  childi'cn,  as  the  membrane,  the  profuse  secre- 
tion, and  the  resulting  (edema  produce  a  rapidly  developing  stenosis 
of  the  larynx.  Suffocation  may  be  prevented  by  tracheotomy.  Tra- 
cheotomy has  a  favorable  influence  upon  the  course  of  the  disease  only 
when  it  is  pei-fonned  ear'ly,  before  a  niai'kc^d  as])liyxia  has  developed, 
and  wlicji  the  disease  remains  limited  to  the  larynx.  If  the  inflannna- 
tion  cxlends  to  11i(^  bronchi,  traelieotomy  will  not-  save  the  patiiuit,  for 
the   fibrinous   masses   fill   the   bronchi   and   their   lu'anches,   and  suffoca- 


e        f 

Fig.  136. — Section  Through  the  Uvula,  from  a  Case 
OF  Pharyngeal,  Diphtheria.  (After  Ziegler.)  a, 
Normal  epithelium;  h,  submucous  connective  Jissue; 
c,  fibrin  with  a  netlike  arrangement;  d,  fibrin  infiltrated 
with  round  cells  lying  upon  necrotic  connective  tissue; 
e,  blood  vessels;  /,  a  hemorrhagic  focus;  g,  groups  of 
micrococci. 


DIPHTHERIA  351 

tion  occurs,  even  if  occasionally  large  masses  of  the  membrane  are 
coughed  up. 

The  general  toxic  infection  causes  clianiics  in  the  nerves  supplying 
the  heart  or  in  the  heart  nuiscle.  Death  often  follows  a  few  days  after 
the  development  of  the  disease,  often  during  convalescence,  from  pa- 
ralysis of  the  vagus,  fatty  degeneration  of  the  heart  muscle, 'or  paralysis 
of  the  cai'diac  ganglia. 

Complications.— A  number  of  complications  which  are  not  fatal  are 
caused  by  the  toxins,  such  as  diseases  of  the  kidneys  (albuminuria  and 
acute  nephritis)  and  the  diphtheritic  paralysis,  which  apparently  is 
an  ascending  neuritis  with  subsequent  central  degeneration  (Baginsky, 
Rainy).  An  early  paralysis  of  the  soft  palate  developing  in  severe  cases 
is  differentiated  from  a  late  paralysis  developing  usually  in  the  second 
and  third  week,  which  recovers  slowly  but  spontaneously.  The  nuiscles 
of  the  palate  and  pharynx  with  disturbance  of  speech  and  swallowing, 
the  extrinsic  muscles  of  the  eye,  and  the  muscles  of  accommodation  arc 
most  frequently  paralyzed;  the  muscles  of  the  face,  vocal  cords,  dia- 
phragm, trunk,  and  extremities  more  rarely.  Hemiplegia  may  be  caused 
by  cerebral  haemorrhage  or  embolism. 

Broncho-pneumonia,  due  to  aspiration  or  extension  of  the  inflam- 
matory process  to  the  lungs,  and  mixed  infections,  particularly^  with 
streptococci,  are  to  be  regarded  as  serious  complications.  Not  only  the 
local  changes,  necrosis  of  the  epithelium,  and  phlegmonous  intlannna- 
tion,  but  also  the  general  symptoms,  become  more  severe  in  poly- 
infections. Then,  usually,  the  clinical  picture  of  a  general  putrefactive 
infection  rapidly  develops.  The  inflamed  nnicous  surface  becomes  cov- 
ered with  a  dirty,  blackish  membrane,  and  a  foul-smelling  secretion  is 
discharged.  There  may  be  some  fever  or  the  temperature  may  be  sub- 
normal, the  patient  rapidly  fails,  the  heart  becomes  w'cak,  liamior- 
rhages  occur  into  the  skin,  the  joints  become  inflamed,  endocarditis 
and  nephritis  may  develop  (putrid  diphtheria).  The  toxins  secreted 
by  putrefactive  bacteria  and  streptococci  are  imi)ortant  factors  in  these 
cases,  as  the  frequent  demonstration  of  streptococci  in  the  blood  and 
the  not  infrequent  inefficiency  of  the  antitoxin  show.  Such  cases  almost 
always  end  fatally  within  a  few  days. 

Diagnosis. — The  diagnosis  of  diphtheria  is  not  difficult  in  acute  cases 
when  the  pathological  changes  in  the  mucous  membranes  are  visible. 
It  may  be  mistaken  for  a  follicular  angina.  In  laryngeal  diphthei'ia 
without  pharyngeal  involvement,  the  examination  of  the  expectorated 
membrane  and  the  laryngoscopic  findings  exclude  other  forms  of  in- 
flammation.    In  adults  it  may  be  confused  with  syphilis  of  the  tonsil. 

In  all  eases  diphtheria  bacilli  should  be  demonstrated  by  cultural 
methods.     If  the  pharynx  is  wiped  with  a  small  piece  of  sterile  gauze 


352  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

or  with  an  applicator,  and  a  number  of  stroke  cultures  are  made,  a 
definite  diagnosis  can  be  made,  after  a  little  practice,  in  twelve  hours. 

Treatment. — It  is  most  important  in  treating  the  local  condition  that 
chemical  or  mechanical  irritation  which  might  favor  the  extension  of 
the  inflammation  and  the  absorption  of  toxins  be  avoided.  In  fact, 
the  great  number  of  agents  (caustics,  antiseptics,  emetics  for  mechanical 
removal  of  the  membrane)  which  have  been  recommended  in  the  treat- 
ment indicate  of  how  little  value  they  have  been. 

On  the  other  hand,  salt  solution,  frequently  inhaled,  and  mild  anti- 
septic gargles  have  a  very  favorable  action  upon  the  inflamed  mucous 
surface  and  favor  the  separation  of  the  membrane. 

Antitoxin  is  of  the  greatest  importance  in  the  general  treatment. 

[The  value  of  antitoxin,  both  for  prophylactic  and  curative  pur- 
poses, has  been  demonstrated.  The  amount  used  for  curative  purposes 
depends  upon  the  virulence  of  the  infection  and  the  time  at  which  the 
patient  is  seen.  The  average  dose  recommended  by  the  United  States 
Pharmacopoeia  is  3,000  units.  The  Chicago  Health  Department  advises 
that  from  3,000  to  8,000  units  be  given  in  ordinary  cases.  From  1,000 
to  1,500  units  should  be  given  when  the  patient  is  first  seen,  and  the 
injection  may  be  repeated  if  there  is  no  improvement  within  twenty- 
four  hours.  In  the  severe  cases,  8,000,  10,000,  and  14,000  units  have 
been  given,  and  the  patients  have  not  suffered  from  such  quantities. 
The  serum  may  be  injected  under  the  skin  of  the  thorax,  thigh,  or  back. 
The  earlier  the  serum  is  injected  the  better  the  results  will  be.] 

Prophylactic  injections  of  from  200  to  500  units  are  to  be  recom- 
mended in  epidemics. 

Results  of  Antitoxin  Treatment. — In  most  cases  a  marked  improve- 
ment is  noted  soon  after  the  injection.  The  inflammation  extends  no 
farther,  the  membrane  becomes  loosened,  the  symptoms  of  stenosis  sub- 
side, the  swelling  of  the  mucous  membrane  disappears,  the  general  con- 
dition improves,  and  the  fever  falls. 

The  mortality  has  been  greatly  reduced  since  the  serum  treatment 
has  been  employed.  Antitoxin  has  caused  a  reduction  of  more  than 
fifty  per  cent  in  the  mortality  (Ricketts)  ;  from  forty-one  per  cent  to 
eight  or  nine  pei-  cent  (Baginsky). 

After  several  days  eruptions  which  resemble  those  of  urticaria  and 
measles,  also  swelling  of  the  joints,  frequently  follow  the  injections. 

In  the  severe  forms,  in  which  gangrene  and  secondary  streptococcic 
infections  develop — the  so-called  putrid  diphtheria — antitoxin  frecpiently 
gives  no  results. 

The  remaining  treatment  should  attempt  to  control  the  symptoms 
and  complications  (cardiac  weakness,  paralysis,  -nephritis,  phlegmons, 
cicatricial  laryngeal  stenosis)   as  they  develop. 


DIPHTHERIA  353 

DIPHTHERIA   OF   THE   SKIN 

Not  infrequently  the  edges  of  tracheotomy  wounds  become  gan- 
grenous. Later  these  wounds  suppurate  and  healthy  granulation  tis- 
sue develops.  Sometimes,  however,  the  gangrene  extends  to  adjacent 
and  deeper  tissues;  the  trachea  and  both  sterno-cleido-niastoid  nniscles 
may  then  become  exposed  and  large  defects  in  the  anterior  wall  of  the 
trachea  may  develop. 

This  acute  progressive  gangrene  of  wounds  may  be  caused  by  diph- 
theria bacilli.  When  the.se  bacilli  gain  access  to  a  wound  they  produce 
a  coagulation  necrosis  of  its  surfaces  and  a  severe  inflammation  of  the 
surrounding  tissues.  The  surface  of  the  woimd  first  becomes  covered 
with  a  dirty,  grayish  red,  firmly  adherent  membrane,  and  later  the  tis- 
sues become  necrotic  and  gangrenous.  The  necrosis  and  gangrene  may 
extend  beneath  the  edges  of  the  wound. 

General  symptoms,  if  present,  are  the  same  as  those  accompanying 
diphtheria  of  mucous  membranes;  even  paralysis  has  been  observed 
(Billroth).  According  to  Billroth,  wound  diphtheria  was  of  fairly  fre- 
quent occurrence  in  pre-antiseptic  times  in  hospitals  for  children ;  and 
in  severe  epidemics  all  possible  forms  of  accidental-  and  operation- 
wounds  were  attacked. 

It  is  rarely  seen  at  the  present  time,  except  in  tracheotomy  wounds 
in  patients  sick  with  diphtheria.  The  bacteriological  investigations  of 
Brunner  and  others  have  shown,  however,  that  the  earlier  observations 
as  to  the  diphtheritic  nature  of  these  infections  were  correct.  It  has 
also  been  demonstrated  that  diphtheria  bacilli  may  produce  a  diph- 
theritic inflammation  without  general  symptoms,  an  inflammation  with 
a  fibrinous  membrane  (Schottmiiller  and  others),  or,  associated  with 
pyogenic  bacteria,  suppuration   (Brunner,  Tavel,  and  others). 

The  diagnosis  of  mild  forms  of  wound  diphtheria  is  very  difficult. 
^V  grayish  white  or  yellowish  membrane  freijuently  develops  upon 
granulation  tissue  which  has  been  infected  with  streptococci,  staphylo- 
cocci, the  bacillus  pyocyaneus,  etc.,  and  it  is  often  difficult  to  differen- 
tiate between  tliese  infections  and  those  due  to  diphtheria  bacilli.  The 
more  severe  infections  resemble  noma  and  hospital  gangrene,  which  are 
rarely  seen  at  the  present  time.  A  bacteriological  examination  is  impor- 
tant in  all  cases  and  will  determine  the  diagnosis. 

In  the.  local  treatment  of  wound  diphtheria — general  treatment  is 
required  in  only  the  severest  cases — all  agents  which  injure  the  wound 
surfaces  should  be  avoided,  and  the  separation  of  the  diseased  tissue 
and  the  formation  of  healthy  granulations  should  be  favored  by  the 
use  of  moist  dressings. 

It  is  important  to  prevent  the  development  of  diphtheria  in  trache- 


354  WOUND    INFECTIONS   OF    DIFFERENT   ORIGINS 

otomj'  wounds.  After  the  tube  is  introduced,  the  wound  should  be 
lightly  packed  with  iodoform  gauze  to  protect  the  fresh  surfaces  from 
infection  from  the  trachea  until  healthy  granulation  tissue  forms. 

The  first  indication  in  the  treatment  of  diphtheria  patients — who, 
because  of  the  dangers  of  transmitting  the  infection,  should  always  be 
kept  in  isolation  wards — is  to  render  harmless  the  toxins  secreted  by  the 
bacilli.  It  is  to  the  lasting  credit  of  von  Behring  that  he  has  given  us 
not  only  the  fundamental  principles  of  innnunity  against  infectious  dis- 
eases, but  also  a  serum  which  cures  diphtheria. 

Literature. — Baginsky.  Diphtheric  und  diphtheritischer  Krupp.  Wien,  1898, 
Nothnagel's  Handb.,  Bd.  2,  and  Deutsche  Klinik,  Bd.  2,  1903.— M.  Beck.  Diph- 
therie.  In  Kolle-Wassermann's  Handb.  d.  pathog.  Mikroorgan.,  Bd.  2,  1903,  p.  754. 
— V.  Behring.  Die  experinientelle  Begriindung  der  antitoxischen  Diphthericthe- 
rapie.  Deutsche  Klinik,  Bd.  1,  1903,  p.  73;  Diphtheric.  Bibl.  v.  Coler,  Bd.  2.— Brun- 
ner.  Ueber  Wunddiphtheritis.  Berlin,  klin.  Wochenschr.,  1893,  p.  515;  Eine  weitere 
Beobachtung  von  Wunddiphth.  Ibid.,  1894,  p.  310;  Wundinfektion  u.  Wundbe- 
handl.,  Frauenfeld,  1898,  II,  p.  130. — Cohn.  Erfahrungen  iiber  Serumbehandl. 
d.  Diphtheric.  Mitteil.  aus  den  Grenzgebieten,  Bd.  13,  1905. — Ehrlich.  Ueber  die 
Konstitution  des  Diphtheriegiftes.  Deutsche  med.  Wochenschr.,  1898,  p.  597. — Eross. 
Ueber  d.  Mortalitat  d.  Diphtheric.  Jahrb.  f.  Kinderheilk.,  III.  Folge,  Bd.  10,  1905, 
p.  595. — Freymuth  und  Petruschky.  Vulvitis  gangra>nosa  mit  Diphtheriebazillenbe- 
fund.  Deutsche  med.  Wochenschr.,  1898,  p.  232.— Gottstein.  Die  Periodizitat  der 
Diphtheric  u.  ihre  Ursachen.  Berlin,  1903. — GUnther.  Bakteriologie.  Leipzig,  1902. — 
Heim.  Bakteriologie.  Stuttgart,  1898. —  Kronlcin.  Ueber  die  Resultate  der  Diph- 
theriebehandking  mit  besonderer  Beriicksichtigvmg  der  Serumtherapie.  Chir.-Kongress, 
Verhandl.,  1898,  I.-S.,  105. — Kruse,  in  Die  Mikroorganismen  von  Fliigge,  Bd.  2,  Leipzig, 
1896. — Nowack.  Blutbefunde  bei  an  Diphtherie  verstorbenen  Kindern.  Centralbl.  f. 
Bakteriol.,  Bd.  19,  1896,  p.  982. — Rumpf.  Diphtherie.  Handb.  d.  praktischen  Medizin, 
Stuttgart,  1901,  Bd.  5. — Rainy.  On  the  Action  of  Diphth.  Toxin  on  the  Spinal  Sticto- 
chrome  Cells.  Journ.  of  Path,  and  Bact.,  1900,  p.  612. — Schottmiiller.  Wunddiphtherie 
u.  s.  w.  Deutsche  med.  Wochenschr.,  1895,  p.  272. — Tax^el.  Ueber  Wunddiphtherie. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  00,  1901,  p.  460;  Diphtherie.  In  Kocher's  chirurg. 
Enzyklopiidie. — Wieland.  Das  Diphtherieheilserum.  Jahrb.  f.  Kinderheilk.,  Nr.  7, 
Bd.  7,  1904,  p.  527. — Wright  und  Emerson.  Ueber  das  Vorkommen  des  Bak.  diphth. 
ausserhalb  des  Korpers.     Central!)!,  f.  Bakteriol.,  Bd.  16,  1894,  p.  412. 


CHAPTER   V 

ANTHRAX 

Davaine  in  18G3  recognized  lliat  bacteiia  were  the  cause  of  the  dis- 
ease, and  originated  the  name  bacillus  itnthracis.  The  bacilli  culti- 
vated and  described  by  Koch  in  1876  are  slender,  cylindrical,  non-motile 
rods  from  6  to  10  /j.  in  length.  They  are  often  united  in  tissues  and 
culture  media  to  form  long  chains. 


ANTHRAX 


355 


Fig.  137. — Axtiikax  Hacilli. 


The  Bacillus  of  Anthrax. — The  bacilli  stain  witli  aniline  dye.-;,  ha-ino- 
toxylin,  and  by  (iianr.s  method.  A  capsule  surrounds  tln'  bacillus  when 
growing-  in  the  body,  but  it  is  difficult  to  obtain  it  in  culture  media.  If 
present,  the  capsule  appears  in 
stained  preparation  as  a  narrow, 
clenr  zone  about  the  bacillus.  Cle;ir 
oval  spaces,  which  correspond  to 
the  spores,  are  seen  in  bacilli  in 
stained  preparation.  Often  each 
inember  of  a  long  chain  contains  a 
spore,  which  is  set  free  when  the 
bacillus  degenerates.  When  young- 
bacilli  grow  on  fresh  media  they 
swell,  then  rupture  at  one  end  and 
discharge  the  spore.  Anthrax  spores, 
because  so  resistant,  are  especially 
suited  for  testing  the  efficiency  of 
different  methods  of  sterilization. 
They  are  destroyed  by  live  steam  (212°  F.)  in  five  minutes;  dry  heat, 
on  the  other  hand,  even  of  284°  F.,  nmst  act  for  a  longer  time  (three 
houi-s  or  more). 

Method  of  Staining  Spores. — Klein's  method  is  best  suited  for  stain- 
ing anthrax  spores.  In  this  method,  equal  parts  of  a  physiological  salt 
solution  suspension  of  material  containing  anthrax  spores  and  Ziehl's 
carbol-fuchsin  are  mixed  in  a  watch  crystal  or  glass.  This  mixture  is 
heated  until  steam  arises;  then  a  few  drops  are  transferred  to  a  cover 
glass.  After  it  is  dried  it  is  destained  with  a  one  per  cent  solution  of 
sulphuric  acid,  washed  with  sterile  water,  and  counter-stained  with 
dilute  methylene  blue  for  three  or  four  minutes  (Sobernheim). 

Cultural  Characteristics. — The  growth  of  anthrax  bacilli  upon  gela- 
tin is  very  characteristic;  upon  agar  (with  free  access  of  oxygen)  less 
so.  The  borders  of  the  colonies,  which  appear  ns  dark  gray  points, 
have  a  wavy  or  wreathed  appearance,  while  in  st;ih  culliu-cs  iiuinl)er- 
less  processes  grow  out  from  the  needle  ti-ack,  like  the  bars  of  a  feather. 

Effects  of  Symbiosis  with  Other  Bacteria. — The  bacilli  rapidly  die 
in  mixed  cultures  with  the  bacillus  pyoeyaneiis.  The  latter  produces  a 
fermentlike  substance  (pyocyanase)  which  dissolves  anthrax  bacilli 
(Ennnerich).  Streptococci  and  staphylococci  are  antagonistic,  espe- 
cially so  in  the  body. 

Anthrax  in  Experimental  Animals. — White  mice,  guinea  pigs,  and 
rabbits  are  best  suited  for  experimental  purposes.  These  animals  die 
in  from  one  to  three  days  after  the  infection  of  small  cutaneous  wounds 
with  spore-free  and  spore-containing  bacilli.     Large  numbers  of  bacilli 


356  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

are  found  in  the  blood  vessels  of  the  viscera.  According  to  Schimmel- 
busch's  experiments,  the  absorption  of  the  bacilli  is  so  rapid  that  in 
mice  the  amputation  of  the  tail,  a  wound  of  which  has  been  infected, 
does  not  prevent  death,  even  if  performed  as  early  as  ten  minutes  after 
the  infection.  After  a  half  hour,  bacilli  may  be  demonstrated  in  the 
viscera.  Animals  die  rapidly  of  a  general  infection  after  bacilli  are 
rubbed  into  an  intact  skin  (Wasmuth).  Intestinal  ulcers  and,  fatal 
general  infections  follow  feeding  experiments  with  spore-containing 
bacilli.  Spore-free  bacilli  are  killed  by  the  gastric  juice  and  cause  no 
symptoms.  Infections  of  the  respiratory  tract  follow  the  inhalation  of 
infected  dust   (Buchner,  Enderlen). 

Neither  toxins  nor  endotoxins  have  been  demonstrated.  The  toxic 
albuminous  substances  found  in  the  blood  and  viscera  by  Hoffa  and 
others  are  not  to  be  regarded  as  specific  anthrax  toxins,  but  as  toxic 
decomposition  products  (Sobernheim). 

Occurrence  of  Anthrax  Bacilli  Outside  of  the  Body. — Anthrax  spores 
are  discharged  upon  the  surface  of  the  ground  in  the  excreta  of  dis- 
eased animals.  They  remain  viable  in  damp  places  for  a  long  time 
(two  to  three  years),  and  are  widely  distributed  in  all  possible  ways 
by  animals  and  man,  rains,  floods,  etc.,  over  meadows  and  pasture  lands. 
Grazing  animals  (cow,  sheep,  horses)  ingest  the  spores  with  their  food, 
and  for  this  reason  almost  always  develop  the  intestinal  form  of  an- 
thrax. Primary  anthrax  of  the  lung  does  not  occur  in  these  animals; 
anthrax  of  the  skin  but  rarely.  Other  animals  (rats,  dogs,  and  pigs) 
are  immiine. 

Immunization  of  Susceptible  Animals. — Susceptible  animals  may  be 
immunized  by  the  injection  of  attenuated  cultures  (Pasteur's  protective 
inoculation).  The  blood  serum  of  immunized  animals  has  protective 
and  curative  properties,  especially  if,  as  Sobernheim  demonstrated,  the 
serum  and  attenuated  cultures  of  the  bacilli  are  injected  simultaneously 
(mixed  active  and  passive  immunization).  The  serum  treatment  in 
man  was  first  successfully  employed  by  Sclavo  and  Mendez.  [The 
best  known  serums  are  those  of  Sclavo,  prepared  from  the  goat  and 
ass,  and  those  of  Mendez  and  Deutsch.  The  properties  on  which  the 
value  of  the  serums  depends  are  unknown.  Sobernheim  is  very  positive 
in  stating  that  the  bactericidal  power  of  the  animal's  serum  is  not  in- 
creased by  immunization  or  infection,  and  the  existence  of  an  anti- 
toxin is  not  recognized.  As  in  some  other  instances,  immunization 
may  cause  an  increase  in  the  opsonins  wliich  would  render  the  serum 
effective  by  its  power  to  cause  increased  phagocytosis. 

The  method  of  Sobernheim,  that  of  mixed  active  and  passive  im- 
munization, seems  to  be  successful  as  a  prophylactic  measure.  The 
vaccine  consists  of  a  mixture  of  antiserum  and  bacilli.     Immune  and 


ANTHRAX  357 

even  normal  sernnis  may  at  times  agglutinate  the  anthrax  bacillus, 
but  the  reaction  is  inconstant,  and  the  ability  of  an  iiinnune  serum  to 
cause  agglutination  is  no  index  of  its  protective  power.  Agglutination 
is  somewhat  difficult  of  determination  because  of  the  tendency  of  the 
bacillus  to  grow  in  the  form  of  chains.] 

Modes  of  Infection  in  External  Anthrax. — Only  the  external  anthrax 
infections,  which  are  the  most  frequent  of  all  the  forms,  are  of  surgical 
interest.  The  lesions  characteristic  of  external  anthrax  follow  infec- 
tions of  wounds  or  develop  in  the  intact  skin,  apparently  from  the  hair 
follicles.  Naturally,  peo])le  who,  in  their  employment,  come  in  contact 
with  animals  dead  of  the  disease  or  with  the  excreta  of  sick  animals, 
develop  this  disease  most  frequently.  The  uncovered  parts  of  the  body 
are  usually  attacked.  In  W.  Koch's  statistics,  comprising  1,077  cases, 
the  head  and  face  were  involved  490  times,  the  npper  extremities,  espe- 
cially the  hands,  370  times.  Apparently  the  infection  is  frequently 
transferred  by  the  hands  to  the  face  and  other  parts  of  the  body,  v;here 
insignificant  wounds,  scratches,  rhagades,  and  excoriations  provide  the 
infection  atria.  It  is  certain  that  infection  follows  the  use  of  hides  of 
animals  dead  of  anthrax  (caps,  pelts,  sandals,  etc.).  The  infection  may 
be  transmitted  by  the  bites  of  fleas,  or  at  least  transferred  by  infected 
fingers  when  bites  are  scratched. 

Internal  Anthrax. — Pulmonary  Anthrax. — Infections  of  the  Inng 
may  follow  the  inhalation  of  dust  containing  spores.  Pulmonary  an- 
thrax, which  is  most  connnon  in  workers  in  paper  factories,  who  handle 
and  assort  rags,  appears  usually  as  a  double  pneumonia  and  pleurisy 
and  runs  an  acute  course  with  symptoms  of  severe  general  infection, 
ending  fatally  in  a  few  days  (woolsorter's  disease). 

Intestinal  Anthrax. — The  second  form  of  internal  anthrax,  the  in- 
testinal, is  rarer  than  the  pulmonary.  In  this  form  haMuorrhagic  foci, 
which  later  become  gangrenous,  develop,  mostly  in  the  intestines.  In- 
testinal anthrax  may  follow  the  use  of  infected  food  (milk,  flesh,  and 
viscera  of  diseased  animals)  or  the  contact  of  infected  fingers  with  the 
mucous  membranes  of  the  mouth.  The  symptoms  are  severe,  bloody 
diarrhoea,  peritonitis,  and  collapse.  A  general  infection  rapidly  de- 
velops and  death  occurs. 

Both  of  these  forms  of  internal  anthrax  may  accompany  an  exter- 
nal infection,  the  two  forms  developing  simultaneously  or  one  being 
secondary  to  the  other,  the  infection  being  carried  by  emboli  (W. 
Koch). 

External  Anthrax. — Clinically  there  are  two  forms  of  external  an- 
thrax— the  carbuncle  and  the  a^lema.  They  develop  most  frequently  in 
the  skin,  occasionally  in  the  mucous  membranes  of  the  nose  and  mouth 

cavity. 

24 


358  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

Anthrax  Carhuncle. — The  anthrax  carbuncle  develops  in  the  begin- 
ning from  a  small  reddened,  itching  area,  in  which  there  forms  within 
one,  two,  or  more  days  a  small  bluish  red  vesicle  filled  with  a  sero- 
hcemorrhagic  exudate  (anthrax  pustule,  malignant  pustule).  There 
develops  very  soon,  especially  if  the  vesicle  is  pinched  or  scratched,  a 
discolored  crust,  which  appears  as  if  sunken  in  the  inflammatory  infil- 
tration surrounding  it.  The  gangrenous  crust  may  become  as  large  as 
a  quarter  of  a  dollar  or  even  larger  (Fig.  138).     Small  vesicles  with 


Fig.  138. — Anthrax  Carbuncle. 


serohsemorrhagic  contents,  from  which  dark  crusts  develop,  form  upon 
the  inflamed,  oedematous  area.  Frequently  anthrax  bacilli  may  be 
demonstrated  microscopically  and  culturally  in  the  exudate  which  seeps 
out  from  beneath  the  crust,  or  by  injection  into  mice.  If  the  contents 
of  the  vesicles  are  purulent  in  character,  a  secondary  infection  with 
pyogenic  bacteria  has  occurred. 

Anthrax  (Edema. — Anthrax  oedema  most  often  accompanies  anthrax 
carbuncle  of  the  face.  The  cheek  and  neck  may  be  involved  when  a 
pustule  develops  about  the  mouth,  as  the  cedema  tends  to  spread  rapidly 
and  to  involve  large  areas.  It  is  not  sharply  defined  against  the  healthy 
skin  as  the  pustule  is.  Frequently  the  skin  covering  the  cedematous 
and  swollen  area  is  markedly  reddened,  and  when  this  occurs  the  lesion 
has  been  spoken  of  as  anthrax  erysijK^as.  Gangrenous  crusts  develop 
from  the  blebs  forming  in  the  inflamed  area,  and  large  areas  of  skin 
become  necrotic. 

Lymphangilis  and  LywpJtadcnitis. — The  lymphatic  vessels  and  nodes 
soon  become  involved  in  both  forms  of  external  anthrax  and  appear 
as  painful  swollen  cords  and  nodules.  Frequently  the  lymphatics  re- 
tain and  destroy  the  bacteria  and  prevent  the  extension  of  the  inflam- 
mation. If  virulent  bacteria  pass  through  the  lymphatics  or  pass  di- 
rectly into  the  blood  from  fresh  w\iunds,  they  reach  and  are  deposited 
in  the  viscera,  esi)ecially  the  spleen  and  liver,  where  they  develop  rap- 
idly and  in  great  numbers.  They  have  been  found  in  the  severest  fatal 
cases  in  the  blood,  and  it  is  certain  that  they  enter  the  blood  stream 


ANTHRAX  359 

during  the  course  of  an  infection,  but  it  is  much  more  diflficnlt  to  dem- 
onstrate them  than  the  ordinary  pyogenic  bacteria  in  the  circulating 
blood.  It  is  doubtful,  however,  whether  the  bacilli  nniltiply  in  the 
blood  of  man  as  they  do  in  the  blood  of  animals.  They  may  pass 
through  the  placenta  and  the  foetus  may  become  infected. 

After  death,  not  only  anthrax  bacilli,  but  also  dift'erent  foi-ms  of 
pyogenic  bacteria  have  been  cultivated  from  the  blood.  The  anthrax 
pustule  provides  the  infection  atrium  for  these  secondary  infections, 
which  may  produce  local  suppuration  and  abscesses  along  the  lymphatic 
vessels  and  in  the  lymph  nodes. 

Fever. — According  to  K.  Miiller,  local  external  anthrax  is  accom- 
panied by  fever  in  only  tAventy-five  per  cent  of  the  cases.  The  fever 
may  become  quite  high,  but  as  a  rule  it  falls  either  rapidly  or  gradu- 
ally after  a  few  days,  if  the  infection  is  properly  treated.  In  the  severe 
cases  with  general  infection,  characterized  by  diarrhoea,  delirium,  and 
stupor,  the  fever  persists  until  death,  which  occurs  within  a  week. 
Abscesses  along  the  lymphatic  vessels  and  suppuration  of  the  lymph 
nodes  may  follow  secondary  infection  with  pyogenic  bacteria.  These 
secondary  infections  follow  some  injury  of  the  pustule,  such  as  scratch- 
ing or  separating  the  crust.  Bacteria  then  gain  access  to  the  lymphatic 
vessels  and  a  rise  in  temperature  follows  this  new  infection.  A  gen- 
eral anthrax  infection  without  symptoms  of  a  primary  localization 
(skin,  lung,  or  intestines)  is  extremely  rare. 

Diagnosis. — The  diagnosis  of  the  external  forms  of  anthrax  is  not 
difficult,  as  the  appearance  of  the  local  lesions  is  very  characteristic. 
The  diagnosis  is  made  certain  by  finding  the  bacilli  in  the  secretion 
of  the  bleb,  and  in  that  discharged  from  beneath  the  crust;  by  inocu- 
lation of  mice  and  cultural  tests.  The  bacilli,  as  a  rule,  are  found  only 
during  the  first  week  of  the  disease,  as  they  are  later  destroyed  by  the 
tissue  fluids  and  the  antagonistic  pyogenic  bacteria.  In  the  pneumonic 
and  intestinal  forms  the  bacilli  may  be  found  in  the  sputum  and  fa?ces. 

Prognosis. — The  prognosis  varies,  depending  upon  the  position  of 
the  primary  pustule  or  rodema.  Anthrax  of  the  head,  face,  and  neck 
is  the  most  dangerous,  and  from  twenty -three  to  twenty-six  per  cent  of 
these  cases  terminate  fatally.  Aspiration  pneumonia  and  oedema  of  the 
glottis  may  easily  follow  the  swelling  of  the  neck.  According  to  Nas- 
sarow's  statistics,  the  mortality  in  anthrax  of  the  upper  extremity  is 
fourteen  per  cent,  of  the  lower  extremit}^  five  per  cent.  The  mortality 
in  internal  anthrax  is  of  course  much  higher  (fifty  to  eighty  per  cent). 

It  should  be  remembered  that  virulent  bacilli  may  be  absorbed  and 
a  general  infection  develop  from  external  anthrax,  notwithstanding  the 
fact  that  only  one  fifth  of  the  cases  end  fatally  and  that  the  disease 
remains  localized  much  more  frequently  in  man  than  in  animals.     As 


360  WOUND    INFECTIONS   OF    DIFFiniFNT    OUlCilNS 

a  rule  the  bacilli  are  destroyed  in  a  short  time  by  the  bactericidal  sub- 
stances in  the  tissue  fluids. 

Treatment. — In  the  treatment  of  external  anthrax  everything  should 
be  avoided  which  favors  the  absorption  of  bacteria.  This  is  most  apt 
to  follow  scratching,  incision  and  excision  of  the  carbuncle  and  infected 
lymph  nodes,  but  may  occur  after  any  manipulation,  such  as  cauteri- 
zation, the  frequent  injection  of  antiseptic  solutions,  the  continuous 
application  and  changing  of  moist  dressings.  Even  extensive  car- 
buncles and  aHiema  heal  spontaneously,  and  any  such  procedures  are 
absolutely  unnecessary  and  often  are  to  blame  for  the  poor  results 
which  follow  in  these  cases.  In  the  severest  cases,  in  which  a  general 
infection  rapidly  develops,  an  operation  is  no  longer  of  any  value. 

The  chief  indication,  therefore,  is  not  to  injure  the  infected  tissues, 
as  any  interference  may  be  followed  by  an  infection  of  the  blood.  It 
is  sufficient  to  cover  the  inflamed  area  with  a  layer  of  gauze,  thickly 
covered  with  salve,  to  prevent  rubbing  by  the  bandages.  An  immo- 
bilizing dressing  sliould  then  be  applied  and  the  extremity  elevated  or 
suspended.  The  inflammation  and  the  fever  subside  vinder  this  treat- 
ment, and  the  crust  becomes  loosened  spontaneously  during  the  second 
week. 

It  is  a  mistake  to  attempt  to  loosen  the  crust  with  tissue  forceps,  for 
the  granulation  tissue  is  injured  in  this  way  and  infection  atria  are 
provided  for  pyogenic  bacteria.  Lymphangitis  and  abscesses  may  then 
develop.  The  immobilizing  dressing  should  be  allowed  to  remain  until 
the  swelling  of  the  lymph  nodes  subsides  and  should  not  be  changed  too 
frequently. 

Abscesses  caused  by  secondary  infections  should  be  incised.  Defects 
of  the  lips  and  eyelids  resulting  from  necrosis  of  the  skin  should  be 
repaired  by  plastic  operation  after  the  disease  has  subsided. 

How  important  rest  of  the  infected  tissue  is  in  prevention  of  a 
general  infet^tion  may  be  illustrated  by  the  results  of  two  different 
experiments  made  upon  mice,  which  are  very  susceptible  to  the  disease. 
Friedrich  ainpiitatcd  llie  tail  of  a  mouse  and  placed  the  stump  in  a 
bouillon  culture  of  vii'ulent  bacilli.  He  so  fixed  the  animal  that  the 
stump  would  be  suspended  for  some  hours  in  the  culture  and  still  not 
be  exposed  to  any  mechanical  in-itatiou.  Absorption  with  general  in- 
fection did  not  follow,  and  tlie  animal  survived.  In  the  other  experi- 
ment Schiirnnell)usch  amputated  the  tail  and  then  rubbed  a  few  drops 
of  a  virulent  culture  into  the  wound  with  a  knife,  and  a  general  infec- 
tion developed   imiiiedintely. 

rrophyldxis. — In  Uie  prophylaxis,  tlu^  transmission  of  the  disease  by 
infected  animals  should  be  prevented.  Dead  animals,  together  Avith 
their  hides,  should  be  buried  in  deep  pits  or  burned  in  furnaces.     No 


GLANDERS  361 

part  of  the  dead  animal  should  1)o  used  foi-  eoniiiiorcial  purposes.  Es- 
pecial euro  should  be  exei'eised  in  disinfecting-  the  stables.  People 
exposed  to  infection  should  be  clean  and  observe  the  usual  precautions 
which  are  taken  against  infectious  diseases. 

The  serum  treatment  may  be  tried  in  the  severer  cases  {vide  pp.  356 
and  357). 

Literature. — Burow.  LTeber  die  Bekampfung  des  Milzbrandes  nach  der  Methode 
Sobernheim.  Berlin,  tiertirztl.  Wochenschr.,  1903,  No.  3"). — Conrudi.  Zur  Frage  der 
Toxinbildung  bei  den  Milzbrandbalvterien.  Zeitschr.  f.  Hygiene,  Bd.  31,  1899,  p.  287. — 
Friedrich.  Bedeutung  des  innergeweblichen  Druckes  fiir  das  Zustandekoninien  der 
Wundinfektion.  Arch.  f.  klin.  Chir.,  Bd.  59,  1889,  p.  458.— TV.  Koch.  Mil/.brand  und 
Rauschbrand.  Deutsche  Chir.,  188G. — Lubarsch.  Milzbrand  bei  Menschen  und  Tieren. 
Ergebn.  d.  path.  Anat.  von  Lubarsch  und  Ostertag  5.  Jahrg.,  1898. — K.  Midler.  Der 
iiussere  Milzbrand  des  Menschen.  Deutsche  med.  Wochenschrift,  1894,  p.  515. — 
Nicolaier.  Zoonosen.  Im  Handb.  d.  prakt.  Med.  von  Ebstein  und  Schwalbe. — Sobern- 
heim. Experim.  Untersuchungen  zur  Frage  der  aktiven  und  passiven  Milzbrandimmu- 
nitat.  Zeitschr.  f.  Hygiene,  Bd.  25,  1897,  p.  301;  Weitere  Mitteilungen  iiber  aktive 
und  passive  Milzbrandimmunitat.  Berl.  klin.  Wochenschr.,  1899,  p.  273;  Milzbrand. 
In  KoUe-Wassermann's  Handl).  d.  pathog.  Mikroorganisnien.  Bd.  2,  1903,1).  1,  and 
Lnniunitat  bei  Milzbrand.     Ibid.,  Bd.  4,  1904,  p.  793. 


CHAPTER    YI 

GLANDERS 

Glanders  Bacilli. — The  bacilli  of  glanders  (Loffler  and  Schlitz)  are 
slender,  small,  non-motile  rods  which  do  not  form  spores.  They  slain 
best  with  alkaline,  aniline  dyes.  They  do  not  stain  by  Gram's  method; 
this  is  important  in  making  a  diagnosis.  It  is  rather  difficult  to  stain 
the  bacilli  in  tissues.  Sections  should  be  stained  in  an  alkaline  meth- 
ylene-blue  or  borax  methylene-blue  solution,  and  then  destained  for 
some  minutes  in  the  solution  recommended  by  LiifHer  (10  c.c.  distilled 
water,  2  drops  of  concentrated  sulphuric  acid,  1  drop  of  a  five  per  cent 
solution  of  oxalic  acid). 

Culture  Media  and  Glanders  in  Ani)nah. — The  bacilli  grow  best 
upon  glycerin-agar,  but  also  grow  well  upon  blood  serum.  Their  growth 
upon  gelatin  is  extremely  slow.  The  virulence  of  the  bacilli  diminishes 
rapidly  upon  culture  media,  but  may  be  considerably  increased  by  pass- 
ing them  through  animals.  Guinea  pigs  are  most  susceptible,  and  die 
within  a  few  weeks  after  subcutaneous  injections  of  virulent  bacilli. 
An  ulcer  develops  at  the  point  of  injection  and  the  adjacent  lym])hatic 
nodes  suppurate.  Inflammatory  and  suppurating  foci  develop  in  the 
body,  glanders  nodes  in  the  viscera,  particularly   in  the  lungs,  spleen, 


362  WOUND    INFECTIONS   OF    DIFFERENT   OKIOINS 

and  testicles.  Suppurative  arthritis  and  ulcers  of  the  nasal  nuicous 
membrane  complete  the  clinical  picture. 

Man  appears  not  to  be  very  susceptible  to  the  disease.  In  the  cases 
in  man,  which  are  not  frequent,  the  infection  is  transferred  in  the 
mucus  from  the  mouth  or  nose  or  in  the  pus  discharged  from  ulcers  of 
diseased  animals.  Endemics  of  glanders  occur  in  horses,  donkeys,  and 
mules.  The  infection  develops  most  frequently  in  the  nasal  mucous 
membrane,  where  nodules,  not  sharply  defined  against  the  healthy  sur- 
rounding tissue,  develop.  These  nodules  are  due  to  cellular  infiltra- 
tion, and  soon  break  down  to  form  ulcers.  Large  quantities  of  mucus, 
which  is  as  infectious  as  the  pus  discharged  from  the  ulcers  in  glan- 
ders of  the  skin,  are  secreted  by  the  diseased  nnicous  membranes.  The 
disease  develops,  excepting  the  rare  cases  of  laboratory  infection,  almost 
only  in  people  who  come  in  direct  contact  with  diseased  animals. 

Infection  Atria. — Frequently  small  wouiads  of  the  skin  of  the  hands 
and  face  provide  the  infection  atria.  Babes  and  Cornil  have  demon- 
strated, however,  that  bacilli  when  rubbed  into  uninjured  skin  pene- 
trate the  hair  follicles  and  may  cause  a  general  infection.  More  rarely 
in  man  are  the  conjunctiva  and  the  mucous  membranes  of  the  lip  and 
nose,  which  are  frequently  the  seat  of  rhagades  and  small  wounds, 
primarily  infected.  Infection  of  the  genital  organs  and  transmission 
by  coitus  have  been  known   (Strube). 

Character  of  Local  Changes. — Small  cellular  nodules,  which  later 
become  necrotic  and  form  ulcers,  develop  in  the  mucous  membrane 
when  infected.  The  infection  may  extend  and  involve  the  lower  parts 
of  the  respiratory  tract.  If  the  skin  is  infected,  small  cutaneous  and 
subcutaneous  nodular  infiltrations,  which  resemble  a  carbuncle,  de- 
velop. These  are  associated  with  the  symptoms  of  acute  inflammation, 
the  epidermis  is  raised  by  an  exudate  and  a  glanders  pustule  forms  or 
the  area  becomes  gangrenous,  and  phagedenic  ulcers  with  undermined 
edges  and  dirty  floors  develop.  If  the  nodules  of  granulation  tissue, 
which  are  often  accompanied  by  an  erysipelatous  inflammation  of  the 
skin,  extend  into  the  subcutaneous  tissue,  abscesses  develop  from  which 
is  discharged  a  thin,  foul-smelling  pus. 

Clinical  'Forms.— Acute  Glanders— 31  ct  astatic  Foci—These  local 
changes  arc  accompanied  by  a  fever,  which  not  infrequently  begins 
without  a  chill  and  general  symptoms.  The  adjacent  lymphatic  nodes 
become  painful  and  swollen  and  suppurate  (glanders  bubo),  and  nodules 
form  along  the  course  of  the  lymphatic  vessels  from  which  ulcers  and 
abscesses  develop.  The  bacilli  of  glanders  are  carried  to  dififerent  parts 
of  the  body  by  the  blood,  in  which  they  may  be  found  during  life. 
Many  metastatic  foci  develop  in  the  form  of  inflammatory  nodules, 
iiodiilai-  infill  rations,  and  abscesses.     These  metastatic  foci  are  i)roduced 


GLANDERS  363 

by  infected  emboli,  for  often  many  thrombi,  loaded  with  bacilli,  are 
found  in  the  veins  of  the  primary  focus.  In  rare  cases  suppurative 
arthritis  and  osteomyelitis  (osteomyelitis  malleosa,  Virchow)  develop. 
Frequently  metastatic  abscesses  develop  in  the  subcutaneous  tissues, 
and  especially  in  the  nuiscles,  while  in  the  viscera,  especially  in  the 
lung,  nodules  composed  of  round  cells,  which  later  suppurate  and  give 
rise  to  the  symptoms  of  bronchitis  and  pneumonia,  form.  Pustules 
resembling  those  of  pemphigus  and  small])()x  develop  in  the  skin  sec- 
ondary to  the  lodgment  of  bacterial  and  infected  emboli ;  ulcers  likewise 
develop  in  the  mucous  membranes  of  the  respiratory  passages,  nose, 
pharynx,  and  larynx.  The  skin  covering  the  abscesses  and  infiltrated 
areas  is  reddened.  The  borders  of  this  redness  are  sharply  defined  as 
in  erysipelas,  but  do  not  extend.  The  general  symptoms  are  fever, 
delirium,  coma,  vomiting,  and  diarrhrea.  These,  in  acute  glanders,  grow 
progressively  worse  and  persist  until  death,  which  occurs  in  two  or 
three  weeks.  Death  is  due  either  to  a  general  bacterial  infection  or 
exhaustion. 

Subacute  and  Chronic  Forms. — The  subacute  and  chronic  forms 
may  persist  for  many  months  or  years.  Recovery  occurs  in  about  one 
half  of  the  cases,  if  the  acute  form  does  not  develop.  The  local  process 
gradually  extends  with  but  few  general  symptoms,  producing  large 
defects  \n  the  skin,  the  infiltration  of  the  skin  occurring  in  the  form 
of  large  nodules,  worndike  or  wreathlike  strands  (the  name  "  worm  " 
has  been  applied  to  the  chronic  forms),  from  which  gradually  develop 
irregular  ulcers,  fused  with  each  other.  If  these  ulcers  have  sharp 
borders  and  a  reniform  shape,  due  to  cicatrization  upon  one  side  only, 
so  characteristic  of  the  ulcerating  gumma,  the  disease  may  be  mistaken 
for  syphilis,  especially  if  the  ulcers  are  situated  upon  the  lips,  the 
palate,  at  the  entrance  to  or  upon  the  mucous  membrane  of  the  nose. 
In  the  chronic  form  of  glanders,  metastatic  suppurating  foci  develop 
only  exceptionally,  and  are  then  single  and  occur  after  long,  irregular 
intervals. 

Diagnosis. — The  diagnosis  of  glanders  is  most  difficult  in  the  chronic 
forms.  The  acute  forms,  especially  in  the  beginning  or  in  cases  without 
a  demonstrable  primary  focus,  may  be  confused  with  typhoid  fever, 
articular  rheumatism,  or  general  pyogenic  infections.  Often  the  inef- 
ficiency of  the  mercury  or  potassium  iotlid  treatment  of  certain  lesions 
of  the  skin  first  suggests  glanders.  It  may  be  mistaken  for  actinomy- 
cosis or  tuberculosis,  and  for  that  reason  the  name  lupus  malleosus  has 
been  applied  to  that  form  of  skin  glandei's  which  resembles  lupus. 

Intraperitoneal  injections  of  pus  from  a  suspected  focus  into  a 
guinea  pig  may  be  employed  as  suggested  by  Straus  in  order  to  make 
a  positive  diagnosis.     In  two  or  three  days  after  intraperitoneal  injec- 


364  WOUND    INFECTIONS   OF    DIFFERENT   ORIGINS 

tions  of  glanders  bacilli  the  testicles  become  infiltrated  and  swollen,  and 
a  suppurative  inflammation  of  the  tunica  vaginalis  develops,  if  the 
animal  does  not  die  of  a  mixed  infection.  Of  course  cultures  should  be 
made  and  smears  examined  in  doubtful  cases. 

Mallein  for  Diagnostic  Purposes. — Mallein,  a  sterile  cultural  ex- 
tract (Kalning,  Preusse),  is  of  doubtful  value  for  diagnostic  purposes. 
[*'  Although  it  causes  a  rise  in  temperature  in  normal  animals  when 
given  in  considerable  doses,  the  reaction  produced  in  infected  animals 
is  so  much  more  intense,  and  occurs  with  so  much  smaller  doses  that 
it  is  generally  considered  as  specific  in  nature.  Some  doubt,  however, 
has  been  thrown  on  the  specificity  of  the  reaction  from  the  facts  reported 
by  various  observers  that  toxic  substances  from  other  organisms,  as  tu- 
berculin and  preparations  from  the  pneumobacillus  of  Friedlander,  the 
bacillus  pyocyaneus,  etc.,  cause  similar  phenomena  in  animals  suffering 
from  glanders.  Wladimiroff  asserts,  however,  that  the  reaction  caused 
by  these  substances  difi'ers  from  that  of  mallein." — Ricketts,  "  Infec- 
tion, Immunity,  and  Serum  Therapy,"  p.  457.]  Bonome  is  the  only 
one  who  has  reported  a  febrile  reaction  after  an  injection  of  mallein 
into  a  patient  sick  with  chronic  glanders.  Zieler  obtained  in  two  cases 
neither  a  general  nor  a  local  reaction  worth  mentioning.  Apparently 
mallein  has  not  the  diagnostic  significance  in  man  that  it  has  in  horses. 

Treatment. — As  a  rule,  treatment  is  powerless  in  the  severe  acute 
forms  of  glanders.  In  these  cases  there  is  always  a  general  infection, 
which  cannot  be  prevented  by  either  sparing  or  destroying  the  pri- 
mary focus.  Amputation  may  prevent  the  general  infection,  if  per- 
formed as  soon  as  the  diagnosis  is  made.  In  the  mild  forms  im- 
provement follows  excision  of  the  accessible  ulcers  and  nodules  and 
incision  of  the  abscesses.  Sometimes  the  disease  subsides  under  this 
treatment  and  the  patient  recovers.  But  all  measures,  such  as  curet- 
ting with  a  sharp  spoon  and  rulibing  the  lesions  with  gauze  saturated 
with  antiseptic  solution,  which  favor  the  extension  of  the  bacteria  to  the 
lymphatic  vessels  and  blood  vessels,  should  be  avoided.  The  resistance 
and  nutrition  of  the  body  should  be  increased  and  the  heart  stimu- 
lated.    Different  indications  should  be  met  as  they  arise. 

Accoi-ding  to  (Jolds,  inunctions  of  mercury  ointment  act  favorably. 
He  tried  this  treatment  in  two  severe  cases  which  recovered.  Other 
authoi-s  have  not  seen  any  improvement,  even  in  the  mild  chronic  cases, 
and  the  inefficiency  of  the  mercury  treatment  has  led  many  to  change 
from  a  diagnosis  of  sy])liilis  to  a  diagnosis  of  chronic  glanders. 

LrrKitATUKi;.  -liolliiif/cr,  in  v.  Zieinsscii's  llandl).  li.  sprz.  Path.  u.  Thcr.,  Bd.  .S. — 
lionome.  La  Riforina  iiunl.,  181)4  (Malknnwirkung). — Buschke.  Ucber  chronischpn 
Rotz  (Icr  inensfhliclK'n'lIaut  Arrh.  f.  Dorm.  u.  Syph.,  Bd.  36,  1896,  p.  32H.—Ehr!rh. 
Zur  Syiiiptomalolof^io  and  Patliolof^io  des  Rotzes  beiiii  Mciischcn.     Bcitr.  z.  klin.  C'hir., 


Ae'TlNUMYCUSIS 


365 


Bd.  17,  1896,  p.  1. — Krusc,  in  Die  Mikroorganismen  von  Fliigge,  Bd.  2,  1896. — Kilhne. 
Ueber  Farbung  der  Bazillen  in  Malleusknoten.  Fortschritte  der  Med.,  1888. — Georg 
Mayer.  Zur  Kenntnis  des  Rotzbazillus  uiid  des  RotzkniUchcns.  Centralbl.  f.  Bakteriol., 
Btl.  28,  1900,  p.  673.— Preusse.  Berl.  ficrarztl.  Wochonschr.,  1898  (Malleiiiinipfungcn). 
— Struhe.  Ueber  Rotzkrankheit  beim  Menschen.  Arch.  f.  klin.  Chir.,  Bd.  61,  1900,  p. 
376. — VircJiow.  Die  krankhaften  Geschwiilste.  Rotz  und  Wunn,  Bd.  2,  p.  543. — 
WldtlimirofJ.  Rotz.  In  KoUe-Wasserniann's  Handb.  der  pathog.  Mikroorganisnien, 
Bd.  2,  1903,  p.  707;— Immunitat  bei  Rotz.  Ibid.,  Bd.  4,  1904,  p.  1020.— Zie/er.  Ueber 
chron.  Rotz  beim  Menschen,  nebst  Bemerkungen  iiber  seine  Diagnose  u.  medizinalpolizei- 
Hche  Bedeutung,  den  Wert  des  Malleins.     Zeitschr.  f.  Hygiene,  Bd.  45,  1903,  p.  309. 


CHAPTER    \ll 


ACTINOMYCOSIS 


The  ray  fiingiis  was  first  seen  by  von  Langcnbeek  (1845)  in  the 
granular  pus  of  a  gravitation  abscess,  secondary  to  caries  of  the  ver- 
tebra". Its  microscopic  appearance  was  later  described  by  James  Israel 
(1878).  A  year  before  this,  Bollinger  had  found  a  similar  fungus  in 
the    granulation  tumors   occurring   upon   the   jaws   of   cattle.      Ponfick 

demonstrated  that 
the  disease  in  man 
and  animals  was 
produced  by  the 
same  fungus.  0. 
Israel  in  1884  was 
the  first  to  obtain 
pure  cultui-es. 


-i-^ 


Fig.  139a. — Section  Through  a  Fully  Devei.oped  Colony. 
(.A.fter  Bostrom.)  a,  Point  at  which  central  filamentous 
mass  breaks  through  the  external  layer  of  clubs;  b,  germinal 
layer  surrounded  hv  clubs. 


Fig.  139^.  —  Sixtion 
Thkough  .\  Degen- 
erated Colony. 
(After  Bostrom.) 


The  Ray  Fungus. — MorpJiologij. — There  ai-c  found  in  aclinoiiiycotie 
tumors  or  in  the  pus  discharged  from  them  light  yellow  granules,  vary- 


366 


WOUND   INFECTIONS   OF    DIFFERENT   ORIGINS 


ing  in  size  from  a  grain  of  sand  to  the  head  of  a  pin,  rarely  larger. 
Each  granule  represents  a  colony  of  micro-organisms.  According  to 
Bostrom,  the  colony  consists  of  an  external  layer  of  radially  arranged 
clubs,  the  central  ends  of  which  become  continuous  with  central  fila- 
mentous masses  (mycelia).  There  are  two  zones  within  the  central 
mass.  In  the  peripheral  zone  (germinal  layer)  the  filaments  are 
arranged  in  a  radiating  manner  and  run  outward  in  a  wavy  or  spiral 
course.  In  the  central  zone,  which  is  less  dense,  the  fibers  interlace  and 
break  through  the  surrounding  layer  of  clubs  at  one  point  and  grow 
into  the  tissues. 

The  isolated  filaments  are  branched  and  have  a  wavy  outline,  differ- 
ing in  these  ways  from  the  ordinary  bacteria.  Bacilluslike  cells  and 
coccuslike  bodies  may  develop  from  the  solid  filament.  These  may 
become  free  and,  according  to  Bostrom,  are  to  be  regarded  as  spores. 
Entire  colonies  may  develop  from  single  elements  of  the  filamentous 
mass,  from  the  spores  as  well  as  from  the  fragments  of  filaments,  but  not 
from  the  clubs.     The  filaments  grow  rapidly  and  produce  the  disease, 


Fig.  140. — Actinomyces.  (After  Schlopol.)  (1)  Branclicd  filament  with  terminal  enlarge- 
ments; (2)  long  branched  filament  broken  up  into  bacilluslike  structures  of  different 
lengths,  which  are  held  together  by  the  sheath  of  the  fungus;  (3)  the  division  of  the 
filament  is  still  more  advanced,  indicating  the  transition  of  the  bacilluslike  structure 
into  bodies  resembling  cocci. 


while  the  clubs  are  to  be  regarded  as  degeneration  forms,  incapable  of 
further  development.  Swelling  of  the  end  of  the  filament  is  the  first  in- 
dication of  the  formation  of  clubs.  [According  to  Wright,  the  radially 
arranged  clubs,  which  give  to  the  organism  the  name  of  "  ray  fungus," 
are  a  manifestation  of  parasitic  existence.]      They  are  found  in   the 


ACTINOMYCOSIS  307 

deeper  parts  of  cultures,  but  are  not  found  in  younjj;  colonies.  Tn  old 
colonies  they  form  a  very  thick  layer  or  are  calcilied. 

Groivtk  upon  Dijferent  Culture  Media. — The  ray  fungus  grows  upon 
all  media,  but  somewhat  slowly.  According  to  Bostrom,  failures  are 
frequent  when  old  colonies  of  contaminated  material  are  used,  and  a 
number  of  tubes  should  therefore  be  prepared.  The  growth  becomes 
visible  during  the  first  day  in  the  foi-m  of  small  dewdroplike  points 
from  which  develop,  within  two  weeks,  small  yellowish  I'ed  granules. 
Granules  form  in  bouillon  without  clouding  the  media.  ]\Iany  varieties 
of  the  fungus,  such  as  those  studied  by  Bostrom,  grow  best  under  aerobic 
conditions,  while  others,  such  as  those  investigated  by  J.  Israel  and 
Wolif,  grow  best  under  anaerobic  conditions. 

Methods  of  Staining. — The  filaments  stain  with  aniline  dyes  and  by 
Gram's  method.  A  colony  may  be  doubly  stained,  using  gentian  violet 
for  the  filaments  and  picrocarmine  and  eosin  for  the  clubs.  In  staining 
sections.  Gram's  method  may  be  combined  with  carmine  or  the  clubs 
may  be  heavily  stained  with  eosin  and  the  tissues  with  hamiotoxylin. 

Experimental  Inoculation  and  Botanical  Classification. — It  is  dif- 
ficult to  transmit  the  disease  to  animals  by  inoculating  ihom  even  with 
pure  cultures.  J.  Israel  and  M.  AVolf  produced,  by  making  intraperi- 
toneal injections  of  cultures  into  ra])bits  and  guinea  pigs,  small  granu- 
lation tumors  which  contained  the  fungus. 

There  is  a  wide  difference  of  opinion  among  authorities  as  to  the 
exact  botanical  classification  of  the  fungus.  ["  By  some  investigators 
ray  fungi  are  considered  as  an  independent  family  midway  between 
the  hypliomycetes  and  the  schizomycetes  (bacteria)  ;  others  place  them 
under  the  hyphomycetes  in  the  group  of  the  streptothrix ;  while  still 
others  consider  them  as  pleomorphous  bacteria,  placing  them  in  the 
group  cladothrix.  Petruschky  recognizes  actinomyces,  streptothrix, 
cladothrix,  and  leptothrix  as  genera  in  the  family  trichomyces,  the 
latter  belonging  to  the  order  hyphomyces.  Biological  variations  which 
have  been  encountered  have  led  to  the  recognition  of  several  species 
of  actinomyces,  among  which  are  a  number  of  non-pathogenic  forms. 
Wright  limits  the  term  actinomyces  to  those  strains  which  produce 
colonies  of  club-shaped  organisms  in  animal  tissues." — Ricketts,  "  In- 
fection, Immunity,  and  Serum  Therapy,"  pp.  459  and  460.] 

Occurrence  and  Distribution  of  the  Fungus. — The  ray  fungus  occurs 
upon  grains  and  straw.  Parts  of  grain  and  parts  of  straw  to  which 
the  ray  fungus  was  adherent  have  been  found  in  the  intlaiumatory 
swellings  produced  by  the  fungus  in  animals  and  man.  Berestncw  could 
demonstrate  fungi,  after  careful  search,  upon  dried  plants,  hay,  straw, 
and  grains.  Liebmann  has  shown  that  after  inocidating  earth  with 
ray  fungi,  the  latter  may  be  found  in  different  jiai-ts  of  plnntod  and 


368 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


r 


gorminatiny;  vegetal)les  and  grains  (beans, 
rye,  barley). 

Modes  of  Infection. — The  infection  in  man 
as  well  as  in  animals  is  transmitted  most 
freqnently,  as  Bostrom  has  demonstrated, 
upon  particles  of  grain.  These  penetrate 
the  skin,  or,  in  people  who  are  accustomed 
to  chew  grain  or  who  accidentally  swallow 
it,  pass  into  the  mncons  membrane  of  the 
mouth  cavity,  pharynx,  oesophagus,  respira- 
tory tract,  and  intestine. 

The  infection  may  be  transmitted  by 
other  foreign  bodies  (e.  g.,  splinters  of 
wood)   to  which  fungi  are  attached. 

Where  the  characteristic  inflammation  is 
not  at  first  superficial,  but  develops  in  the 
deeper  tissues,  it  is  probable  that  some  for- 
eign body  has  carried  the  fungus.  Grains 
provided  with  barbs  {vide  Fig.  141)  are 
apparently  able  to  penetrate  deeply  into  the 
tissues. 

The  ray  fungus  may  also  pass  directly 
into  the  tissues.  Clinical  findings  indicate 
that  actinomj'cosis  of  the  jaw  and  cheek  fre- 
quently develops  from  carious  teeth  (Israel, 
Partsch).  Partsch  has  found  ray  fungi  in 
the  cavities  of  carious  teeth,  and  in  one  case 
the  fungus  had  passed  down  to  the  end  of 
the  root  canal.  There  is  no  doubt  that  in- 
fection may  occur  in  this  way.  Other  cases 
in  which  the  symptoms  of  actinomycosis  de- 
velop, after  a  fracture  of  the  mandible,  after 
acute  periostitis  following  extraction  of 
teeth,  indicate  that  the  wound  or  inflam- 
matory focus  was  secondarily  infected  with 
the  fungus.  In  these  cases  the  micro-organ- 
isms had  ap])arently  been  sapi'()])]iytic  for 
some  time. 

Action  of  the  Ray  Fungus  and  Character 
of  the  Lesions. — The  ray  fungus  produces  in 
1h(!  1  issues  a  chronic,  progressive  inflamma- 
lion.  Its  colonies  are  sui'rounded  by  a  wide 
area    of   giaiiulation   and   connective   tissues, 


ACTLNOMYCOSLS 


369 


Avhich  are  undermined  by  the  fungi.  Not  infrequently  in  man  it 
produces  tumorlike  growths,  which  in  cattle  were  considered  for  a 
long  time  to  be  of  a  sarcomatous  nature.  The  proliferation  of  the 
cellular  elements  is  far  greater  than  the  exudation  and  degeneration, 
which  are  most  marked  in  other  forms  of  inflammation.  The  inflam- 
matory new  growth  is,  as  von  Esmarch  has  aptly  described  it,  of  board- 
like hardness,  and  is  sharply  delimited  from  the  surrounding  licaltliy 
tissue.  It  is  adherent  to  the  deeper  structures  and  fused  with  the  skin, 
if  the  inflammatory  process  has  already  extended  to  the  surface.  The 
granulation  tissue  undergoes  fatty  changes  and  becomes  licpiefied. 
Small  suppurating  foci,  the  skin  covering  which  becomes  bluish  red  in 
color,  develop  as  the  process  extends  to  the  surface.  Finally  these  rup- 
ture through  the  skin,  and  fistula?  are  formed  from  which  is  discharged 
pus,  which  contains  the  characteristic  sulphur-yellow  granules  (colonies 
of  ray  fungi)  and  necrotic  granulation  tissue.  These  fistnhe  are  chronic 
and  become  longer  and  more  branched  as  new  foci  develop,  which  dis- 
charge into  them.  An 
acute  process  accom- 
panied by  fever  and 
associated  with  the  for- 
mation of  phlegmons  and 
abscesses  is  never  caused 
by  ray  fungi  alone.  In 
such  cases  there  is  a  sec- 
ondary infection  with 
pyogenic  bacteria.  When 
the  foci  are  large  and 
extensive,  the  general 
condition  of  the  patient 
rapidly  deteriorates  and 
a  cachexia,  which  may 
prove  fatal,  may  develop. 
According  to  our 
present  knowledge  the 
lymphatic  vessels  and 
nodes  are  not  involved 
in  actinomycosis  except 
in  rare  cases.  The  infec- 
tion may  be  carried  by 
the  blood,  however,  when 
the   ray    fungus   invades 

a  vein  in  the  primary  focus  in  wliidi  a  tlirombus  is  developing.     Then 
metastatic  foci  may  develop  in  any  tissue  or  viscus,  even  occasionally 


Fig.  142. 


n.KXIATOC.KNOUS  OSTEOMYELITIS  OP  THE  FeMUR 

Caused  hy  the  Ray  Fungus. 


370 


WOUND   INFECTIONS  OF   DIFFERENT  ORIGINS 


in  the  bones  (Fig.  142,  Wrede).  The  clinical  course  of  a  general  in- 
fection with  the  ray  fungus,  which  is  always  fatal,  is  similar  to  that  of 
the  chronic  pyogenic  infections  with  metastases. 

Actinomycosis  in  Man. — Depending  upon  the  point  at  which  the 
infection  occurs,  actinomycosis  in  man  may  be  divided  into  four  groups : 
(1)  Actinomycosis  of  the  mouth  cavity,  (2)  of  the  lungs,  (3)  of  the 
intestines,  (4)  of  the  skin. 

Actinomycosis  of  the  Mouth,  Face,  and  Head. — Infections  of  the  face 
and  cheek  are  placed  in  the  first  group.  They  either  develop  in  the 
mucous  membrane  of  the  cheek  directly,  or  extend  from  the  mucous 


Fio.    14.3. — ArTTNOMYCosTR    OF   THE    Face    AND    Neck.      (From    Rcvan's    Surgical    Clinic.) 


UKniibraiies  of  the  upper  and  lowoi*  jaws  and  fi-om  carious  teeth.  Tn 
the  former  ease  there  may  be  only  a  slight  infiltration  of  the  gum.  An- 
chylosis of  the  jaw,  an  early  and  important  symptom  of  the  disease,  de- 


ACTINOMYCOSIS 


371 


velops  as  the  inflammation  in  the  cheek  extends,  and  the  muscles  of 
mastication  become  involved  in  the  inflammatory  mass.  The  muscles 
of  mastication  are  not  involved  in  the  small,  rapidly  softening  foci 
which  form  about  the  opening  of  Stenson's  duct  (Schlange)  and  de- 
velop in  the  middle  of  the  cheek  anterior  to  the  masseter  muscle.  Fre- 
([uently  a  cordlike,  indurated  process,  extending  beneath  the  nuicous 
membrane  of  the  cheek  to  the  alveolar  process  or  a  carious  tooth,  may 
be  felt.  This  indicates  the  way  in  which  the  inflammation  has  traveled. 
The  inflammatory  swelling,  firmly  connected  with  the  underlying  bones, 
extends  from  the  cheek  to  the  submaxillary  and  temj)oral  regions.  The 
temporal  region  is  also  involved  when  the  inflannnation  extends  upward 
along  the  internal  surface  of  the  ramus  of  the  mandible.  Actinomy- 
cosis of  the  maxilla  may 
extend  to  the  orbital 
and  nasal  cavities,  or 
may  rupture  through  the 
base  of  the  skull  and 
produce  a  fatal  menin- 
gitis or  encephalitis.  The 
process  may  extend  from 
the  jaw  or  pharynx  to 
the  prevertebral  tissues, 
with  secondary  destruc- 
tion of  the  vertebras. 
Gravitation  abscesses  then 
pass  along  the  anterior 
surface  of  the  vertebrae 
and  an  abscess  may  de- 
velop in  the  abdominal  i- 
cavity,  secondary  to  a 
focus  in  the  mouth  or 
pharynx.  Only  rarely 
do  central  foci  develop 
in  the  jaw  secondary  to 
a  focus  in  an  alveolus. 

The  point  of  infection  in  cervical  actinomycosis  is  most  f^i'e« incut  ly 
in  the  pharynx,  if  the  disease  has  not  extended  from  a  focus  about  the 
jaw.  The  tonsils  and  retropharyngeal  tissues  are  most  frequently  in- 
volved first;  occasionally  the  point  of  infection  is  in  the  nuicous  mem- 
brane of  the  oesophagus  or  larynx.  The  transverse,  bluish  red,  indu- 
rated folds  in  the  skin  in  which  small  subcutaneous  abscesses  develop 
are  very  characteristic  of  actinomycosis  of  the  neck  (Fig.  144).  The 
formation  of  chronic  flstultv  and  the  discharge  of  colonies  of  ray  fungi 


Fig.  144. — Actinomycosis  ok   imk 
(After  Illich.) 


) 


Neck. 


372  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

make  the  diagnosis  certain.  The  swelling  may  become  so  extensive  as 
to  render  movements  of  the  neck  impossible  and  to  intei-ferc  with 
swallowing  and  breathing. 

Actinomycosis  of  the  tongne,  occurring  in  the  form  of  a  nodulai-  infil- 
tration, is  rare.  This  may  be  easily  mistaken  for  a  gnnnna,  and  if 
softened,  for  the  ordinary  abscess ;  occasionally  for  a  carcinomatous 
induration  of  the  floor  of  the  mouth. 

Actinomycosis  of  tlie  Lungs. — Primary  actinomycosis  may  develop 
in  any  part  of  the  lungs;  most  frequently,  however,  in  the  lower  lobes. 
This  form  generally  follows  aspiration  of  the  ray  fungus  from  the 
mucous  membranes  of  the  mouth  or  pharynx.  Israel's  demonstration 
of  a  piece  of  a  tooth  in  a  pneumonic  focus  is  very  significant  from  an 
etiological  viewpoint.  ]\Iost  frequently  a  broncho-pneumonic  focus  de- 
velops; occasional]}^  a  superficial  catarrhal  inflammation.  A  wide  area 
of  the  lung  surrounding  a  focus  becomes  indurated.  There  is  a  tend- 
ency for  this  area  to  become  necrotic  and  to  undergo  cicatricial  con- 
traction. The  peculiarity  of  actinomycosis  of  the  lung,  in  the  early 
stages  resembling  tuberculosis,  is  its  tendency  to  spread  to  neighboring 
tissues  and  not  to  remain  limited  to  the  lungs.  The  part  of  the  lung 
involved  undergoes  considerable  cicatricial  contraction.  When  the  in- 
flammation reaches  the  pleura  a  serous  pleuritis  develops  or  the  two 
leaves  of  the  pleura  become  united  and  transformed  into  a  thick  cica- 
tricial mass.  Sui)purating  foci,  which  later  rupture  externally,  develop 
in  this  newly  formed  tissue.  A  number  of  fistula  then  discharge  upon 
the  surface  of  the  chest,  or  a  hard,  tumorlike  swelling,  which  later  rup- 
tures through  the  skin,  develops  over  the  ribs.  The  inflammation  may 
extend  to  the  pericardium,  or  an  abscess  may  rupture  through  the  dia- 
phragm at  its  point  of  attachment  to  the  vertebi'a^  and  extend  to  the 
abdominal  cavity  or  pelvis.  Abscesses  of  the  spleen  and  liver  or  peri- 
tonitis may  be  caused  in  this  Avay.  A  secondary  actinomycosis  of  the 
lungs  develo])s  when  an  abdominal  form  extends  to  the  thorax  or  when 
emboli,  which  may  be  easily  carried  into  the  pulmonary  veins  from  the 
primary  focus,  lodge  in  the  lung.  Ray  fungi  may  be  fcmnd  in  the 
spuluin  in  all  forms  of  actinomycosis  of  the  lungs.  If  not  found,  the 
disease  should  not,  however,  be  excluded. 

Actinomycosis  of  the  Intestines. — Intestinal  actinomycosis  begins 
most  frequentl.y  in  the  ca'cum,  and  in  the  parts  of  the  small  and  large 
intestine  innnediately  adjacent  to  it.  Other  parts  of  the  gastro-intes- 
tinal  tra(!t  (stomach,  small  intestine,  sigmoid  flexure,  and  rectum)  are 
but  rarely  primarily  involved.  The  sym])toms  of  intestinal  actinomy- 
cosis develop  slowl^y  and  are  often  obscure.  Intestinal  actinomycosis 
often  res(>mbles  acute  appendicitis  because  of  fever,  local  pain,  and  the 
f)osition  of  the  induration.     If  the  process  extends  through  the  intes- 


ACTINOMYCOSIS  373 

tinal  wall  to  snrronnding  tissues,  adhesive  peritonitis  and  larije  indu- 
rated masses,  resembling  tumors,  may  develop.  Tlie  necrotic  tissue  and 
abscesses,  in  which  are  sometimes  found  particles  of  grain,  apparently 
the  cause  of  the  infection,  may  rupture  in  any  direction.  They  may 
ulcerate  into  the  intestine,  bladder,  or  rectum.  I\Iost  frequently,  how- 
ever, these  abscesses  rupture  externally.  In  the  latter  case,  numerous 
fistulfe  open  iipon  the  surface  of  the  abdomen,  especially  in  the  region 
of  the  umbilicus  and  the  right  groin,  or  in  the  lumbar  and  gluteal 
regions,  if  the  abscesses  have  developed  in  the  retroperitoneal  tissue  to 
which  the  inflammation  frequently  extends.  Fa'cal  fistula?  are  conunon. 
In  some  cases  it  is  difficult  to  determine  whether  or  not  the  indurated 
mass  beneath  the  skin  has  developed  from  an  intestinal  lesion,  for  some- 
times the  deep-lying  and  small  mass  about  the  intestine  escapes  the 
palpating  finger  or  has  already  disappeared.  The  infection  may  be 
carried  by  the  portal  vein  to  the  liver.  Actinomycosis  of  the  latter 
organ  is  observed  in  extensive  abdominal  actinomycosis  as  well  as  in 
general  infections  with  metastases.  Embolic  foci  develop  in  the  intes- 
tinal wall  in  general  actinomycosis. 

Actinomycosis  of  the  Skin. — Actinomycosis  of  the  skin  is  most  com- 
monly secondary  to  one  of  the  forms  mentioned  above.  Primary  acti- 
nomycosis of  the  skin  does  occur  after  penetrating  wounds  by  foreign 
bodies,  to  which  ray  fungi  are  attached.  Pieces  of  grain  frequently 
carry  the  infection.  Lupuslike  nodules,  nodular  infiltrations,  abscesses, 
ulcers,  and  fistulte  slowly  develop  about  the  wound.  Deep-lying,  infil- 
trated areas,  which  gradually  surround  the  bone,  may  resemble  clinic- 
ally a  chronic  form  of  suppurative  osteomyelitis.  For  example,  von 
Bergmann  observed  a  case  in  which  the  lower  part  of  the  femur  was 
surrounded  by  a  large  indurated  mass.  This  developed  within  five 
years  and  followed  a  kick  by  a  horse  in  which  tissues  surrounding  the 
bone  had  been  cut. 

Diagnosis. — The  diagnosis  of  actinomycosis  is  dil'ficult,  though  pos- 
sible, so  long  as  the  foci  have  not  ruptured  externally.  The  microscopic 
demonstration  of  the  ray  fungus  in  the  pus  makes  the  diagnosis  cer- 
tain. The  pus  must  be  examined  inunediately  as  the  fungi  lose  their 
characteristic  clubs  within  a  day.  There  may  be  no  colonies  in  the 
secretion,  and  one  may  look  over  a  number  of  sections  without  finding 
them.  The  chronic  course  of  actinomycosis  may  be  altered  by  mixed 
infection.  Acute  phlegmons  and  abscesses  then  develop,  the  true  nature 
of  which  may  be  recognized  when  they  are  incised  or,  later,  when  the 
fistuke  and  hard  nodules  develop.  If  the  inflammatory  new  growth  is 
prominent,  actinomycosis  may  be  mistaken  for  sarcoma,  gunnna,  or 
possibly  for  the  enlargement  of  bone  which  follows  acute  i)yogenic 
infections.     Examination  of  indurated  cords,  extending  to  the  jaw,  help 


374  WOUND   INFECTIONS  OF   DIFFERENT  ORIGINS 

in  making  a  diagnosis  of  actinomycosis  of  the  cheek.  In  intestinal  acti- 
nomycosis the  fungi  may  be  found  in  the  faeces;  they  may  be  found 
in  the  sputum  when  the  lungs  are  involved. 

Prognosis. — The  prognosis  varies  in  the  different  forms.  Schlange 
has  made  the  important  observation  that  the  more  superficial  foci  may 
heal  spontaneously  after  the  discharge  of  the  necrotic  tissue  laden  with 
fungi.  The  prognosis  is  most  favorable  in  actinomycosis  of  the  head 
and  neck.  Actinomycosis  of  the  luiigs  and  intestines  is  frequently  fatal. 
The  disease  always  proves  fatal  when  the  inflammation  extends  to  vital 
organs  and  into  deeper  parts,  especially  along  the  vertebral  colunm 
into  the  pelvis,  and  when  a  general  infection  develops  through  the 
blood. 

Treatment. — In  the  treatment,  naturally,  an  attempt  should  be  made 
to  aid  healing,  Avhich  occurs  when  the  fungi  are  encapsulated  or  dis- 
charged externally.  It  is  not  necessary  to  remove  the  indurated  mass, 
as  is  the  case  in  the  treatment  of  tumors.  The  fistulous  tract  should 
be  followed,  and  the  small  granulating  and  suppurating  foci  exposed 
and  removed  with  a  sharp  spoon.  These  incisions  must  be  repeated 
if  large  indurated  masses  remain.  Under  the  open  treatment  with  iodo- 
form gauze,  complete  healing  occurs  after  weeks  or  months  without  the 
injection  of  antiseptic  solutions  so  often  recommended.  Potassium 
iodid  is  of  value.  Actinomycosis  of  the  lung  and  intestine,  when  not 
too  extensive,  may  be  cured,  if  the  point  at  which  the  abscess  ruptures 
is  directly  over  the  primary  focus  (Schlange,  Karewski),  and  if  this 
focus  can  be  exposed  by  incision  of  the  soft  tissues  or  resection  of  ribs 
and  the  greater  part  of  the  focus  removed.  [In  the  Bevan  clinic,  where 
a  relatively  large  number  of  cases  have  been  treated  lately,  excellent 
results  have  followed  the  use  of  copper  sulphate  administered  in  a  one 
fourth  grain  pill  three  times  a  day,  and  irrigation  of  the  focus,  when 
possible,  with  a  one  per  cent  solution  of  copper. sulphate.] 

Foci  which  are  not  accessible  should  be  protected  from  secondary 
infection.  The  skin  surrounding  the  fistula?  should  be  sterilized  and 
aseptic  dressings  applied.  The  general  condition  of  the  patient  should 
l)e  impi'oved.  The  fresh  air,  outdoor  ti-eatment  employed  in  cases  of 
tuberculosis  is  of  great  value. 

LiTEUATUHE. — V.  Bamcz.  Ilcber  die  Actinoinykose  ties  Menschen.  Arch.  f.  klin. 
Chir.,  Ikl.  G8,  1902,  p.  1050. — Bostrom.  Untersuchungon  iiber  die  Aktinomykose  des 
Menschen.  Ziegler's  Beitr.  z.  path.  Anatomie,  Bd.  9,  1890,  p.  1. — Heinzelmann.  Die 
Endresultate  der  Behandlung  dcr  Aktinomykose.  Beitr.  z.  klin.  Chir.,  Bd.  39,  1903,  p. 
526. — Herz.  Ueber  Aktinomykose  des  Verdauungsapparates.  Centralbl.  f.  d.  Grenzgeb. 
1900,  p.  561. — Hummel.  Zur  Entstehung  dor  Aktinomykose  durch  eingedrungene 
Frcrndkorpor.  Beitr.  z.  klin.  Chir.,  Bd.  \^^,  1895,  p.  534. — Illich.  Beitrag  zur  Klinik  der 
Aktinoinykosc.  Wion,  1892. — /.  Israd.  Klinische  lioitnige  zur  Aktinomykose  des 
Menschen.     Berlin,   1885; — None  licobachfuiigcn   auf  dcm  Gebicte  der  Mykosen  des 


MADURA   FOOT  375 

Menschen.  Virchow's  Arch.,  Bd.  74,  1878,  p.  15. — J.  Israel  und  M.  Wolff.  Ueber 
Reinkultur  des  Aktinomyzes  und  seine  Uebertragbarkeit  auf  Tiere.  Virchow's  Arch., 
Bd.  126,  1891,  p.  11  and  Bd.  151,  1898,  p.  Hi.— O.  Israel.  Ueber  die  Kultivierbarkeit 
des  Aktinomyzes.  Virchow's  Arch.,  Bd.  95,  1884,  p.  140. — Karewski.  Beitrag  zur 
Lehre  der  Aktinomykose  der  Lunge  und  des  Thorax.  Verhandl.  tier  Bcrl.  med.  Ges., 
1899. — -Kruse,  in  Die  Mikroorganismen  von  Fliigge,  Bd.  2. — Lachner-Sandoval.  Ueber 
Strahlenpilze.  Strassburg,  Beust,  1898. — Lieblein.  Ueber  die  Aktinomji-kose  der 
Haut.  Beitr.  z.  klin.  Chir.,  Bd.  27,  1900,  p.  766; — Ueber  die  JodkaHunibehand- 
lung  der  menschhchen  Aktinomykose.  Ibid.  Bd.  28,  1900,  p.  198. — W.  Muller. 
Ueber  Aktinomykose  der  Brustlcriise.  Miinch.  med.  Wochenschrift,  1894,  p.  1027. — 
Pctruschky.  Die  pathogenen  Tricliomyzeten.  Hantlb.  der  pathog.  Mikroorganismen 
von  Kolle-Wassermann,  Bd.  2,  1903,  p.  832. — Poncet  et  Berard.  De  I'actinomycose 
humaine  en  France.  Gaz.  hebdom.  de  med.  et  de  chir.,  1902,  No.  27. — Schlange. 
Zur  Prognose  der  Aktinomykose.  Arch.  f.  klin.  Chir.,  Bd.  44,  1892,  p.  876. — Schlegel. 
Aktinomykose.  Handb.  der  pathog.  Mikroorganismen  von  Kolle-Wassermann,  Bd. 
2,  1903,  p.  861. — Silberschmidt.  Ueber  Aktinomykose.  Zeitschr.  f.  Hygiene  und 
Infektionskrankh.,  Bd.  37,  1901,  p.  345. — Tusini.  Ueber  die  Aktinomykose  des 
Fusses.  Arch.  f.  klin.  Chir.,  Bd.  62,  1900,  p.  249. — Wrede.  Hiimatogene  Osteomyelitis 
durch  aktinomyzes.  Chir.-Kongr.  Verhandl.,  1906. — Bevan  and  Post.  Actinomycosis. 
Chicago  Medical  Recorder,  Oct.,  1905. 


CHAPTER    YIII 

MADURA   FOOT 

By  Madura  foot  is  understood  a  characteristic,  clirouic,  progressive 
inflammation  which  occurs  most  frequently  upon  the  feet;  occasionally 
upon  the  hands.  It  was  first  observed  in  Madura  (India,  1712),  then 
in  Hindustan.     Occasionally  cases  are  seen  in  America  and  Africa. 

The  disease  begins  with  a  painless  swelling  of  the  sole  of  the  foot, 
usually  only  one  foot  being  involved.  It  runs  a  chronic  course,  during 
which  round,  bluish  red,  confluent,  soft  nodules  form,  which  rupture, 
leading  to  the  formation  of  chrcmic  fistula?.  The  latter  heal,  but  .soon 
break  open  again.  Gradually  the  inflammation  extends  to  tjie  dorsum 
of  the  foot  and  extends  deeper,  involving  the  tendons  and  joints,  the 
periosteum,  and  bone,  the  latter  being  completely  destroyed  or  trans- 
formed into  a  number  of  cavities.  The  jnis  discharged  from  these  le- 
sions is  thin,  foul-smelling,  and  contains  small  yellow  or  black  granules. 

The  Madura  foot  fungus,  which  grows  well  upon  glyeerin-agar, 
apparently  belongs  to  the  streptothrix  group.  [''  Pure  cultures  of  the 
organism,  which  is  called  streptothrix  madura'  (Vincent)  were  first 
obtained  by  Vincent  in  1894,  and  have  been  studied  by  a  number  of 
observers  since  that  time.  It  bears  a  close  resemblance  to  the  acti- 
nomyces,  and  by  some  is  considered  a  variety  of  that  organism.  Differ- 
ences between  the  black  and  yellow  varieties  are  not  clearly  set  forth." 


376  WOUND    INFECTIONS   OF    DIFFIQIENT    ORIGINS 

— Ricketts,  "  Infection,  Immunity,  and  Sei'ura  Therapy,"  p.  462.]  The 
absence  of  clubs  differentiates  it  from  the  ray  fungus.  The  tissue 
changes  produced  by  this  fungus  are  similar  to  those  produced  by  the 
ray  fungus. 

Permanent  cure  follows  amputation.  If  the  part  involved  is  not 
amputated,  the  patient  gradually  loses  strength  and  becomes  cachectic. 
In  the  beginning  of  the  disease  incision  and  curettage  of  the  separate 
foci  may  be  tried. 

Literature. — Babes.  Der  Madurafuss.  In  Kolle-Wassermann's  Handb.  dor 
pathog.  Mikroorganismen,  Bd.  3,  1903,  p.  454,  with  Lit. — Bollinger.  Ueber  primare 
Aktinomykose  der  Fusswurzelknochen.     Miinch.  med.  Wochenschr.,  1903,  p.  2. 


CHAPTER    IX 

BLASTOMYCOSIS  ^ 

Introduction. — Blastomycosis  was  first  brought  to  the  notice  of  the 
scientific  world  in  INIay,  189-1,  since  which  time  its  position  has  been 
attacked  and  defended  by  able  men.  At  present  there  are  only  a  few 
who  are  unwilling  to  accept  the  disease  as  an  entity.  During  the  past 
four  5'ears  the  imioortance  of  the  affection  has  been  emphasized  by  mul- 
tiplication of  the  niunber  of  cases  recognized  (now  more  than  one  hun- 
dred) and  by  the  gravity  of  the  disorder  when  general  infection  occurs. 
Fifteen  or  more  systemic  cases  have  been  recognized  and  studied. 
Among  other  names  prominently  connected  with  the  development  and 
study  of  the  disease  clinically,  experimentally,  microscopically,  etc., 
should  be  mentioned  Gilchrist,  Busse,  Buschke,  Hyde,  Montgomery 
(Frank  Hugh),  Ilektoen,  Bevan,  and  Ricketts. 

Since  general  infection  has  been  recognized  as  a  prominent  feature 
of  the  disease,  tlie  term  blastomycosis  has  been  generally  adopted,  the 
original  term,  blastomycetic  dermatitis,  given  by  Gilchrist,  being  too 
narrow.  In  those  cases  where  the  infection  is  confined  to  the  skin,  the 
term  "  cutaneous  blastomycosis  "  is  applied,  while  the  generalized  in- 
fections are  usually  designated  as  "  systemic,"  "  generalized,"  or 
"  disseminated  "  blastomycosis. 

History. — In  ]\Iay,  1894,  Gilchrist  demonstrated  sections  of  a  "  pe- 
culiar skin  disease  "  before  the  American  Dermatological  Association, 
in  which  the  organisms  of  this  disorder  were  noted  and  described.  The 
previous  clinical  diagnosis  in  this  case,  made  by  Duhring,  was  "  scrofu- 

•  For  complete  abstracts  of  oases  of  systemic  blastomycosis,  see  Transactions  of 
Sixth  International  Congress  of  Dermatology,  1907. 


BLASTOMYCOSIS  377 

lodernia."  Gilchrist  and  Stokes,  in  July,  180G,  made  a  report  of  this 
ease,  and  again  more  fully  in  1S*J8.  Six  months  after  (Jilehrist's  dem- 
onstration of  the  sections,  Busse  published  an  ai-ticie  reporting  his  case, 
and  again  with  Buschke  in  a  more  extended  study  with  a  report  in 
1895  and  1899.  In  1896  Curtis  reported  his  study  of  a  case  of  what 
he  termed  "  saccharomycose  humaiue."  Then  followed  reports  of  eases 
termed  "  hlastomyeetic  dermatitis,"  the  term  adopted  by  Gilchrist,  by 
the  following  gentlemen:  In  1898  Wells,  IlessU'r,  Hyde,  Ilektoen,  and 
Bevan,  with  a  further  study  of  the  organism  from  the  latter  ease  by 
Hektoen  in  1899 ;  in  1899  Owens,  I^isendrath  and  Ready,  and  ]\Iurphy 
and  Ilektoen;  in  1900  Anthony  and  Ilerzog,  Coates,  Baldwin,  Brayton 
(three  cases  in  April,  1900,  July,  1901,  and  February,  1902)  ;  ]\Iont- 
gomerj^  (Frank  Hugh)  (case  reported  before  the  American  Dermato- 
logical  Association),  with  a  further  report,  with  two  additional  cases 
by  Montgomery  and  Ricketts  in  January,  1901 ;  in  1901  Dyer,  Stel- 
wagon,  Harris,  etc.,  since  which  time  cases  have  multiplied  until  a 
large  number  has  been  recorded.  From  early  in  1908  until  the  present 
time  cutaneous  blastomycosis  has  not  been  reported  to  any  extent  from 
Chicago;  not  that  observations  have  been  wanting,  for  new  cases  are 
constantly  coming  under  observation. 

Notwithstanding  the  fact  that  in  the  second  recorded  case  of  blasto- 
mycosis (that  of  Busse)  a  general  infection  occurred,  much  doubt  has 
existed  concerning  general  infection ;  this  doubt,  however,  has  been 
dispelled  by  subsequent  observations. 

The  first  recorded  general  iufection  was  that  of  Busse  in  1894,  the 
second  that  of  ]\lontgoniery  and  Walker  in  April,  1902.  Further  re- 
ports of  cases,  with  study  more  or  less  complete,  frequently  including 
autopsy  records,  have  been  recorded  by  Ornisby  and  IMiller  in  IMarch, 
1903;  by  Cleary  in  ]\Iay,  1904;  by  Eisi-ndrath  aiul  Ormsby  in  October, 
1905,  with  additional  clinical  findings  and  autopsy  report  in  the  same 
case  by  LeCount  and  i\Ieyer  in  IMarch,  1907,  and  Bassoe  in  December, 
1905;  in  1906  by  Irons  and  Graham  and  Ilektoen  aiul  Christenson  (two 
cases)  ;  in  1907,  by  Baum  and  Stober  (demonstrated  before  the  Chicago 
Dermatological  Society)  ;  by  Gar\y  (paper  read  before  branch  of  Chi- 
cago IMedical  Society)  and  IMontgomery  (Frank  Hugh),  this  ease  was 
demonstrated  by  Dr.  ]\Iontgomery  before  the  Chicago  Dermatological 
Society  in  April,  1905.  In  addition  to  these,  we  have  seen  three  cases 
not  recorded. 

Blastomycetes  were  first  demonstrated  in  th(>  spittu)))  in  the  case 
of  Eisendrath  and  Ormsby  in  1905,  and  in  fecal  mailer  from  the  same 
case  in  1906  as  recorded  by  LeCount  and  IMeyer. 

Geographical  Distribution. — In  the  United  States,  Chicago  is  appar- 
ently the  center  of  infection,  as  the  majority  of  cases,  both  of  cutaneous 


378 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


and  systemic  blastomycosis,  have  been  recoi-ded  there.  In  addition,  cases 
have  been  noted  in  Indiana,  Wisconsin,  Nebraska,  Texas,  Massachusetts, 
Kentucky,  Colorado,  Utah,  Maryland,  New  York,  Michigan,  Minnesota, 
and  Iowa.  Among  the  foreign  countries  may  be  mentioned  Canada, 
England,  Germany,  France,  Scotland,  Japan,  India,  Italy,  and  South 
America. 

Organs  and  Tissues  Involved. — In  the  victims  of  the  disorder  coming 
to  the  post-mortem  table,  blastomycetes  have  been  demonstrated  in  the 
following   organs:    larynx,   trachea,   lungs,   pleura,  myocardium,   liver, 

spleen,  pancreas,  kid- 
neys, adrenals,  lymph 
glands,  bones,  joints,  sub- 
cutaneous and  cutaneous 
tissues,  brain,  spinal 
cord,  and  colon.  The 
organisms  have  been 
demonstrated  in  sputum 
and  in  fecal  matter.^ 

Clinical  Symptoms  in 
Cutaneous  Cases.  —  The 
age  of  the  patient  has 
varied  from  twelve  to 
seventy-four  years.  Le- 
sions have  occurred  over 
practically  the  entire  cu- 
taneous surface,  the  face 
having  been  the  site  of 
election  in  a  great  num- 
ber of  cases;  the  region 
about  the  cheeks  and  eye- 
lids is  frequently  at- 
tacked. The  size  of  the 
lesions  has  varied  from 
a  small  beginning  pap- 
ulo-pustule  to  large 
patches  several  inches  in 
diameter.  In  the  case 
used  for  illustration 
(Figs.  145,  146,  and 
147)     nine    patches     ex- 


r 

W         '-^S^K      '"^^Kw    *'ni^^l 

>     ^'-^ipMHI 

^r 

^HHI 

^^^^^^^^^^^^BTfi 

Fia.  145. — Cutaneous' Blastomycosis  Showing  Deli- 
CATE  ScAH  Tissue  in  the  Center  with  Active  Ad- 
vancing BonDER. 


•  Since  the  above  was  written,  blastomycetes  have  been  found  in  the  prostate  gland 
and  in  the  urine. 


BLASTOMYCOSIS 


379 


istecl,  some  of  which  covered  an  area  of  several  inches.  The  lesion  begins 
as  a  small  papule,  or  papulo-piistule,  which  spreads  peripherally,  event- 
ually forming  a  patch  of  varying  dimensions.  A  patch  the  size  of  a 
silver  quarter  presents  the  following  characteristics: 

It  is  surrounded  by  a  bluish  red  areola  in  which  the  small  miliary 
abscesses  characteristic  of  the  disorder  are  found.     The  areola  gradu- 


FiG.   146. — Cutaneous  Blastomycosis  Showing  Circular  Patch  with  Papillomatous 
Elevations  Covering  the  Surface. 


ally  slopes  from  the  elevated  patch  to  the  normal  surrounding  skin, 
and  is  about  one  fourth  of  an  inch  in  width.  The  main  part  of  the 
lesion  is  elevated  about  an  eighth  of  an  inch,  and  the  top  of  the  patch 
is  more  or  less  flat,  papillomatous  or  verrucous,  crust-covered,  or  dis- 
charging, or  superficially  ulcerated.  Pus  nuiy  be  squeezed  from  between 
the  papillomatous  projections,  as  in  verrucous  tuberculosis.  The  mil- 
iary abscesses  in  the  sloping  border  of  the  patch  are  characteristic, 
and  vary  from  minute,  scarcely  visible  points  to  lesions  the  size  of  a 
pin's  head,  and  from  which  a  glairy,  muco-purulent  material  can  be 
obtained,  from  which  the  organisms  may  be  recovered  in  pure  cul- 
ture. In  parts  of  the  patch  which  have  undergone  involution  a  super- 
ficial scar  is  left,  which  is  usually  soft  and  smooth,  but  may  be  irregu- 
lar and  corded.    The  scar,  however,  is  not,  as  a  rule,  disfiguring  except 


380 


WOUND   INFECTIONS  OF   DIFFERENT  ORIGINS 


when   near   the   eyes,   in  which   case  more   or   less   extensive   ectropion 
occurs. 

The  course  of  the  disease  is,  as  a  rule,  chronic  in  the  cutaneous  cases, 
periods  of  activity  and  spreading  alternating  with  periods  of  apparent 


Fig.  147. — Cutaneous  Blastomycosis  Showing  Patch  on  Dorsum  of  Foot. 


quiet.  The  patches  may  be  in  close  proximity  or  separated  by  quite  a 
distance,  as,  for  exami)le,  when  the  patch  exists  on  the  face  near  the 
eye,  with  another  on  the  wrist;  or  again,  one  patch  on  the  face  and  an- 
other on  the  leg  near  tlie  knee,  or  at  the  same  time  on  the  face,  arms, 
legs,  etc.,  various  sized  patches  and  in  varying  degrees  of  activity  may 
be  found.  Often  in  the  scar  of  an  apparently  healed  area  the  small 
abscesses  containing  the  organism  are  noted,  which  may  light  up  into 
activity  at  any  time.  As  JMontgomery  states:  "A  single  patch  may 
at  one  lime  |)fcs<'nt  nil  llie  stages  of  the  disoi'dci',  showing  at  the  same 
tim(!  scvcrjil  of  llic  following  fcalui'cs:  llic  advancing  boi'der,  ncAV  le- 
sions forming  on  old  scars,  verrucous  or  caulillowcn*  lesions  in  various 
stages  of  development  or  disappearance,  a  base  in  places  dry  and  firm 


BLASTOMYCOSIS 


381 


and  in  others  soft  and  infiltrated  with  muco-pus,  a  scar  tissue  in  part 
thick  and  irregular  and  in  part  smooth,  soft,  supple,  and  non-attached 
to  the  deeper  tissue." 

Cutaneous  lesions  occurring  in  systemic  cases  are  described  under 
that  heading. 

Clinical  Symptoms  in  Generalized  Cases. — Tlie  observations  recorded 
in  this  chapter  were  made  from  material  collected  chiefiy  about  Chi- 
cago, with  reference  also  to  findings  recorded  in  literature  from  other 
parts  of  this  country  as  well  as  abroad,  but  no  effort  has  been  made 
to  incorporate  all  the  recorded  cases,  as  that  would  be  beyond  the  scope 
of  this  article. 

In  collecting  data  for  describing  the  clinical  symptoms  and  patho- 
logical findings  of  sy.stemic  or  generalized  cases,  fifteen  recorded  and 


f- 

fr 

^^m 
^^^'* 

\ 

^^v 

HIh 

.     / 

«^L       fc<U^ 

1 

1 

1 

lie;.  1-18. — Ci  TAXEOUS  Lesions  ix  a  Patient  the  Suhject  of  Generalized  Blastomycosis. 
(Courtesy  of  the  Joiir.  of  Cut.  Dis.) 


unrecorded  cases  are  considered.  In  twelve  of  the  patients  the  disease 
proved  fatal.  One  has  apparently  recovered  (Gar\y)  and  two  others 
are  either  well  or  nearly  so  at  the  last  report.  Three  of  the  ea.ses  the 
writer  has  studied  carefully,  and  througli  the  eourte.sy  of  his  colleagues 
has  observed  and  to  some  extent  investiaated  six  others.     Of  these  nine 


382  WOUxND   INFECTIONS   OF   DIFFERENT   ORIGINS 

only  one  is  living.  It  is  readily  seen,  therefore,  that  when  systemic 
involvement  occurs  it  assumes  a  grave  character.  Some  of  the  cases 
have  proved  rapidly  fatal. 

The  symptoms  include  those  arising  from  infection  of  practically 
all  of  the  organs  of  the  body,  but  apparently  the  symptoms  presented 
clinically  are  not  proportionate  to  the  marked  findings  demonstrated 
at  the  post-mortem  table.  For  example,  in  the  case  of  Ormsby  and 
Miller,  only  mild  physical  findings  referable  to  the  lungs  were  noted 
before  death,  and  the  patient  had  only  a  moderate  cough  with  scanty 
expectoration,  yet  the  lungs  were  completely  infiltrated  with  the  tuber- 
cles and  abscesses  peculiar  to  the  disorder.  The  kidneys,  too,  were 
infected,  but  urinary  findings  during  life  were  negative. 

Some  general  symptoms,  however,  have  been  more  or  less  constant. 
An  irregular  temperature  has  been  the  rule,  ranging  from  98^°  to  103° 
F.  One  subject,  however,  had  constantly  a  subnormal  temperature,  96° 
to  98°  F.  (Cleary).  Emaciation  has  been  constant,  and  in  some  cases 
extreme.  Weakness,  with  prostration  and  different  grades  of  anaemia 
have  occurred.  Albumin  with  casts  showing  nephritis  has  been  noted. 
This  was  present  to  a  high  degree  in  the  case  of  Cleary.  Cough  with 
sanguineo-purulent  expectoration  has  been  present  in  several  cases  in 
which  blastomycetes  have  been  demonstrated  (Eisendrath  and  Ormsby, 
Bassoe,  Irons  and  Graham,  and  others).  The  puJse  and  respiration 
have  been  proportionate  to  the  temperature  in  most  cases.  However, 
as  emaciation  increased,  a  feeble,  rapid  pulse  was  the  rule.  Pain  oc- 
curred in  the  chest  in  one  case,  and  severe  pain  in  the  back  in  another. 
(Edema  of  the  extremities,  as  well  as  of  the  face,  has  been  noted.  One 
almost  constant  accompaniment  has  been  the  formation  of  multiple 
subcutaneous  and  cutaneous  abscesses  and  nodules,  which  later  have 
developed  into  ulcers,  their  distribution  at  times  involving  almost  the 
entire  body.  The  ulcers  in  these  cases  result  from  the  breaking  down 
of  the  subcutaneous  abscesses,  and  at  times  cover  large  areas  by  sub- 
sequent burrowing  and  destruction  of  tissue.  The  ulcers  are  irregular 
in  outline,  ill-conditioned,  discharging,  or  crust-covered,  at  times  hav- 
ing fistulous  connections  with  deeper  structures.  Occasionally  metas- 
tatic abscesses  have  been  sufficiently  large  to  hold  within  their  walls 
as  much  as  a  liter  of  pus.  The  pus  in  all  these  has  been  a  product 
of  the  blastomycetes,  as  no  other  germ  has  been  discovered,  while  these 
organisms  have  been  obtained  in  pure  culture.  Diarrhoea,  with  the 
organism  in  the  fecal  matter,  was  noted  by  LeCount  and  Meyer  in  the 
case  of  Eisendrath  and  Ormsby.  Spondylitis  has  occurred  several  times. 
In  one  case  several  vertebiw  were  destroyed  with  a  corresponding 
amount  of  spinal  cord.  In  addition  to  the  vertebiw,  some  of  the  ribs, 
the  tibia,  jiikI  the  cranial  bones  have  been  involved.     Suppurative  ar- 


BLASTOMYCOSIS  383 

thritis  has  occurred  in  several  cases,  lari:e  (|uaiitities  of  pus  liavinu:  lieen 
found  in  the  joints.  Blastoniycotic  laryngitis  has  developed  in  two 
cases,  in  one  of  which  the  organisms  were  demonstrated  in  the  ulcers 
in  the  larynx  (Ormsby  and  Miller).  In  one  case  lesions  were  demon- 
strated in  the  brain. 

The  lymphatic  glands  have  been  exceptionally  free,  but  in  several 
cases  involvement  of  these  organs  has  been  noted. 

The  general  picture,  then,  has  been  that  of  constitutional  involve- 
ment, somewhat  similar  to  tuberculosis,  for  which  disorder  it  has  been 
at  times  mistaken.  Once  (Walker  and  INlontgomery)  the  diagnosis,  both 
clinical  and  by  autopsy,  was  made  of  tuberculosis,  but  on  later  investi- 
gation blastomycetes  were  demonstrated  both  in  the  skin  and  internal 
organs,  with  no  tubercle  bacilli.  IMiliary  tubercles  or  nodules  of  blasto- 
mycosis strongly  suggest  those  of  tuberculosis. 

To  sum  up,  the  clinical  picture  is  nearly  as  follows:  E\'idence  of 
general  infection,  exhibited  by  irregular  temperature,  loss  of  appetite, 
general  weakness,  emaciation,  cough,  w'ith  sanguineo-purulent  or  pos- 
sibly only  frothy  expectoration,  rapid,  feeble  pulse,  acceleration  of  the 
respiration,  at  times  albumin  in  the  urine,  multiple  subcutaneous  nod- 
ules and  abscesses  resulting  in  superficial  irregular  ulcers,  abnormal 
physical  findings  in  the  lungs,  such  as  dullness,  bronchophony,  bronchial 
breathing,  various  rales,  etc.,  oedema  of  the  extremities,  and  various 
grades  of  angemia.  A  combination  of  generally  distributed,  subcutane- 
ous nodides,  abscesses,  and  cutaneous  ulcers,  with  evidence  of  consti- 
tutional disease,  should  always  suggest  generalized,  blastomycosis. 

Cutaneous  Histopathology. — The  original  description  given  by  Gil- 
christ in  his  case,  the  first  one  recorded,  has  had  few  essential  addi- 
tions during  the  many  years  that  have  since  elapsed,  and  his  findings 
have  been  corroborated  by  practically  all  observers.  The  resemblance 
in  the  histological  architecture  between  many  of  these  cases  and  some 
forms  of  cutaneous  tuberculosis  is  striking.  The  epidermal  hyper- 
trophy, the  cellular  infiltration  in  the  corium,  the  partial  or  complete 
destruction  of  collagen  and  elastin  in  areas  most  markedly  affected,  the 
presence  of  many  giant-cells,  the  formation  of  tubercles  or  pseudo- 
tubercles — all  are  found  in  both  disorders.  The  striking  and  char- 
acteristic miliary  abscesses  in  both  the  epidermis  and  corium,  showing 
marked  evidences  of  infiammatory  action  and  containing  the  organisms 
peculiar  to  blastomycosis,  mark  the  special  difference. 

In  blastomycosis  the  chief  pathological  changes  occur  in  the  epi- 
dermis and  the  upper  portion  of  the  corium.  The  stratum  Malpighii 
is  hypertrophied,  sending  prolongations  in  various  directions  into  the 
corium.  In  this  layer  miliary  abscesses  of  various  sizes  occur.  They 
contain  chiefly  polymorpho-nuclear  leucocytes,  fragments  of  epithelial 


384 


WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 


cells  in  various  stages  of  degeneration,  parts  of  nuclei  and  other  de- 
tritus, with  one  or  several  of  the  causative  organisms,  the  latter  usually 
in  pairs.  The  abscesses  vary  in  size  from  those  only  sufficiently  large 
to  contain  a  few  leucocytes  with  one  organism,  to  those  sufficiently  large 
to  be  easily  seen  with  the  naked  eye.  The  wall  of  the  abscess  consists 
of  more  or  less  flattened  epithelial  cells.  Occasionally  the  abscesses 
contain  in  addition  giant-cells,  and  at  times  a  few  plasma-cells.  The 
rest  of  the  rete  is  oedematous,  its  cells  being  swollen;  the  leucocytes 
are  distributed  irregularly  about  and  between  the  cells.     Hypertrophy 


Fig.  149. — Micuoi-iiotograph.  Cutaneous  Section  (High  Power)  Showing  Giant-Cell 
Containing  Organisms  of  Hlastomycosis.  (Courtesy  ol  t]w  Jouriml  of  the  American 
Medical  Association.) 


of  the  rete  (acanthosis)  is  often  so  marked  as  to  suggest  an  epithelio- 
matous  change,  but  with  careful  study  the  basal  layer  is  always  found 
intact.  The  surface  of  the  epidermis  is  irregular,  and  is  covered  with 
epithelial  cell  debris,  fibrin,  pus-  and  blood-cells. 

The  corium  is  the  seat  of  a  cellular  infiltration.  In  the  more  acutely 
inflamed  areas  miliary  abscesses  occur  similar  to  those  in  the  epidermis. 
Those  in  the  center  contain  one  or  several  organisms  surrounded  with 
leucocyt&s,  which  in  turn  are  surrounded  by  connective  tissue  and 
l)lasma-c('lls,  with   m;niy  giant-cells  int(>rspersed.     The  giant-cells  often 


BLA.ST(JMYCO.SIS 


385 


contain  the  orgranism  singly  or  in  pairs;  several  may  he  present.  At 
times  a  space  is  noted,  from  which  an  organism  may  have  escaped 
(Ricketts).  INIast-cells  may  be  few  or  abundant,  and  of  various  shapes, 
depending  on  their  evolution.  In  the  areas  of  dense  infiltration  collagen 
and  elastin  are  diminished  in  amount  or  absent.  The  appendages  of  the 
skin  are  not  actively  involved.  In  the  more  active  areas  miliary  ab- 
scesses with  numerous  organisms  and  leucocytes  predominate;  in  more 
chronic  areas,  giant-  and  iilasma-cells  are  in  excess.  In  some  sections 
large  numbers  of  classical  plasma-cells  are  noted.  Hyaline  degenera- 
tion is  descrilx'd  in  these  cells  by  Eicketts. 

General  Pathology. — The  findings  recorded  hei-e,  both  gross  and 
microscopic,  are  collected  from  the  eight  cases  now  recorded,  with 
autopsy  reports. 

In  view  of  these  findings,  the  striking  and  characteristic  changes 
consist  in  the  presence  of  nodules  or  tubercles  and  abscesses  in  the  soft 
tissues,  and  caries  in  the  bones.  The  organism  of  blastomycosis  is  mark- 
edly pyogenic.  The  nodules  and  ab- 
scesses vary  greatly  in  size,  location, 
and  number  in  different  cases,  but 
are  always  present.  The  character- 
istic composition  of  these  lesions  in 
all  areas  consists,  primarily,  of  the 
organism  of  blastomycosis  in  vary- 
ing numbers,  leucocytes  (polymor- 
pho-nuclear  chiefly,  but  also  mono- 
nuclear) and  giant-celLs;  secondarily, 
of  plasma-  and  mast-cells,  cellular 
and  other  detritus,  pigment,.,  red 
blood  cells,  etc.,  the  latter  being  more 
or  less  abundant,  depending  on  the 
location  and  acuity  of  the  process. 
The  abscesses  vary  in  size  from  those 
which  are  microscopic  to  some  suf- 
ficiently large  to  hold  one  half  liter 
of  pus.  They  may  occur  in  all  the 
organs  of  the  body,  as  well  as  in 
the  bones  and  joints,  and  are  es- 
pecially characteristic  in  the  subcu- 
taneous tissue,  where  at  times  fistulas 
and  large  excavations  are  produced. 
These  abscesses  have  also  been  noted  in  the  glands,  both  abdominal 
and  thoracic,  behind  the  oesophagus  and  in  the  bones  (vertebra;,  ribs, 
tibia,  etc.). 


Fig.  150. — Cut  Section  of  the  Spleen 
Showing  Areas  of  Blastomycotic 
Infii-tration.  (Photograph  courtesy 
of  the  Journal  of  Cutaneous  Diseases.) 


386  WOUND   INFECTIONS  OF   DIFFERENT  ORIGINS 

A  typical  blastomycotic  nodule  has  in  its  center  an  area  of  necrosis, 
with  blastomycetes,  leucocytes,  and  cellular  detritus  surrounded  by 
giant-cells.  It  may  contain  also  connective  tissue,  plasma-,  and  mast- 
cells. 

In  some  cases  great  destruction  of  tissue  has  occurred  in  certain  of 
the  internal  organs.  The  lungs  in  all  cases  have  been  the  seat  of  marked 
changes.  The  nodules  and  abscesses  may  infiltrate  almost  the  entire 
organ.  The  presence  of  large  numbers  of  blastomycetes  with  giant- 
cells  and  leucocytes  is  characteristic.  Giant-cells  always  contain  from 
one  to  several  organisms.  Plasma-  and  mast-cells,  much  pigment,  and 
granular  detritus  are  also  found,  and  in  some  areas  newly  formed  con- 
nective tissue.  In  one  case  a  lung  was  almost  completely  destroyed. 
It  contained  an  enormous  number  of  organisms  in  various  stages  of 
development.  The  process  in  most  cases  is  a  blastomycotic  broncho- 
pneumonia. 

Blastomycotic  nodules  or  tubercles  are  found  in  the  pleura,  in  peri- 
bronchial lymph  glands,  and  in  the  myocardium. 

In  the  abdominal  cavity  the  spleen  has  been  the  seat  of  most  de- 
structive changes,  consisting  of  nodules,  areas  of  necrosis  containing 
granular  detritus,  and  large  numbers  of  the  parasites.  Here  giant- 
cells  have  not  been  conspicuous.  The  liver,  kidneys,  adrenals,  pancreas, 
lymph-glands,  and  colon  have  all  been  the  seat  of  similar  changes  to  a 
less  degree,  except  in  one.  case  where  the  adrenals  (Cleary)  were  exten- 
sively invaded.     Like  the  spleen,  the  adrenals  contained  no  giant-cells. 

The  destructive  process  has  been  marked  in  the  spinal  column  in 
several  cases.  In  one  case  several  vertebrte  were  destroyed,  with  a 
corresponding  length  of  the  spinal  cord.  The  necrotic  areas  in  the 
bones  contain  the  organism  in  large  numbers,  leucocytes,  an  occasional 
giant-cell,  and  a  fibrinous  exudate. 

Amyloid  degeneration  is  not  constant,  but  has  occurred  in  several 
cases  and  may  be  extensive.  It  has  been  found  in  the  liver,  kidneys, 
adrenals,  spleen,  retroperitoneal,  mesenteric,  and  mediastinal  lymph- 
glands,  and  colon. 

Summary  of  Gross  Pathological  Findings. — Blastomycotic  subcuta- 
neous abscesses,  nodules,  sinuses,  ulcers,  and  scars,  covering  practically 
all  parts  of  the  body.  Blastomycotic  laryngitis  and  broncho-pneumonia. 
Blastomycosis  of  the  pleiii-a,  subpleural  and  retropharyngeal  tissue, 
the  peribronchial  lymph-nodes,  the  liver,  spleen,  kidneys,  adrenals, 
colon,  various  bones  (tibia,  ribs,  vertebni?),  the  external  surface  of 
the  spinal  diirn  iiialcr,  the  siiiiial  cofd,  Ihe  cerebellum,  various 
joints  (elbow,  knee,  ankle,  etc.),  chronic  parenchymatous  nephritis, 
atrophy  of  the  heart,  etc.  In  addition  to  the  above,  blastomycotic  areas 
have  been  demonstrated  microscoi3ically  in  the  myocardium,  pancreas, 


BLASTOMYCOSIS 


387 


and   various   lymph   glands,   and    amyloid    degeneration    in    tlie   orirans 
previously  mentioned. 

Description  of  the  Organism  in  Tissue. — The  biological  position  of 
this  organism  has  not  been  })ositively  settled.  In  tissue  its  method  of 
reproduction  is  by  gemmation.  It  is  made  up  of  a  capsule  (at  times  an 
adventitious  capsule  in  addition),  a  clear  zone,  granules,  and  at  times  a 
vacuole.  The  size  varies  from  5  to  15  fx,  but  we  have  many  times 
noted  organisms  as  large 
as  30  fx.  Taken  as  a  p^-^ 
whole,  the  organism  is  ' 
round  or  oval  or  some- 
what irregular,  sur- 
rounded by  a  homoge- 
neous, doubly  contoured, 
refractile  capsule,  im- 
mediately within  which 
is  a  clear  zone,  v/hile 
the  center  contains  gran- 
ules of  various  sizes  and 
shapes,  and  sometimes 
a  vacuole.  These  proto- 
plasmic granules  are  at 
times  basophilic,  demon- 
strated by  their  taking 
the  red  part  of  Unna's 
polychrome  methylene 
blue  stain. 

While  endogenous 
spore-formation  is  not 
proven  in  these  organ- 
isms, one  may  often  see 
ruptured  capsules,  and 
in  the  immediate  neigh- 
borhood   small    granules 

similar  to  those  within  the  capsule.     At  limes  when  numl)ers  of  oi-gan- 
isms  are  present,  crescentic-shaped  capsules  i)artly  tilled  may  be  seen. 

The  organism  is  well  seen  in  fresh  pus  or  tissue  mounted  in  a  ten 
per  cent  solution  of  potassium  hydrate,  and  may  be  easily  stained  with 
any  of  the  common  aniline  dyes. 

Cultural  Characteristics. — In  common  Avith  other  fungi,  blastomy- 
eetes  present  multiform  cultural  appearances,  depending  upon  the  media 
used  and  the  temperature  at  which  they  are  grown.  Ordinarily  they 
grow  well  on  glycerin-  and  glucose-agar,  blood-serum-agar,  and  in  broth. 


Fig.  151. — Smear  from  Tuukrcli;-like  Lesion  in  the 
Splekn,  Mounted  in  Onk  Per  Cent  Potassium 
Hydrate  in  Glycerin,  Showing  the  Organism  op 
Blastomycosis  (X  1000).  (Microphotograph,  courtesy 
of  the  Jour,  of  Cut.  Dis.) 


388 


WOUND   INFECTIONS   OF   DIFFERENT  ORIGINS 


As  a  rule,  a  moist,  pasty  growth  occurs  ou  glycerin-agar  at  room  tem- 
perature, with  only  moderate  aerial  hyphie,  while  more  aerial  hyplue 
form  ou  glucose-agar  and  agar-agar  at  the  same  temperature.  Cultures 
begin  to  develop  in  from  two  to  fourteen  days,  subcultures  usually  in 

from  tAVO  to  five  days. 
Mycelial  formation  is 
more  abundant  during 
the  first  few  weeks,  but 
later  budding -forms  oc- 
cur. In  the  incubator 
the  growth  is  more  moist 
and  pasty,  and  budding- 
forms  are  more  numer- 
ous early.  These  latter 
facts  have  recently  been 
again  demonstrated  by 
Hamburger.  Otis  and 
Evans,  studying  the 
growth  of  the  organism 
isolated  from  a  case  of 
systemic  blastomycosis 
reported  by  Ormsby  and 
IMiller,  noted  that  in 
thirty  hours,  after  a 
hanging  drop  culture  was 
made  in  bouillon,  the  cells 
started  processes  which 
grew  60  [x.  in  length  dur- 
ing the  following  twenty- 
four  hours,  the  mycelia 
being  homogeneous  and 
possessing  a  very  thin  cell  wall;  later  protoplasmic  granules  and  pinkish 
vacuoles  appeared.  After  several  days  a  subdivision  of  the  mycelia  into 
segments  of  vaiying  lengths  occurred.  After  a  hanging  drop  culture  in 
glycerin-agar  had  developed  for  about  a  month,  there  appeared  an  end- 
cell  that  budded,  and  in  the  course  of  several  days  a  group  of  these  cells 
was  noted.  It  may  be  that  the  organisms  develop  in  tissue  by  bud- 
ding only;  on  media  ])y  segmental  mycelial  formation  with  lateral  co- 
nidia,  and  later  by  a  certain  number  of  budding  forms,  the  latter  differ- 
ing, however,  in  some  j)articulars,  from  the  forms  seen  in  fresh  tissue 
and  pus. 

Animal  Experiments. — Both  local  and  general  infections  have  been 
produced    (!X])criiii('ii1ally    in    mice    and    guinea   pigs.      The    latter    are 


Fig.  152. — Groavth  of  the  Organism  of  Blastomycosis 
ON  Glycerin-agar  Twenty-one  Days  Old,  from  a 
Miliary  Abscess  in  the  Spleen,  Showing  Moist, 
Pasty,  and  Wrinkled  Growth.  (Photograph,  cour- 
tesy of  the  Jour,  of  Cut.  Dis.) 


BLASTOMYCOSIS 


389 


rather  resistant  to  infection,  bnt  a  general  infection  may  be  produced 
and  the  organism  later  recovered  from  practically  all  the  viscera  when 
large  doses  of  the  organism  in  culture  are  injected.  The  lungs,  liver, 
spleen,  kidneys,  testicles,  diaphragm,  etc.,  have  been  the  seat  of  tuber- 
cles peculiar  to  the  disorder  in  which  the  causative  organism  has  been 
demonstrated  and  recovered  in  pure  culture.  The  histological  picture 
presented  in  these  various  organs  has  been  similar  to  that  found  in 


-<.S-y1  4>\     u*-     ^/^ 


\\ 


Fig.  l.'SS. — Smear  from  Growth  of  the  Organism  on  Media  Five  Weeks  Old  Mounted 
IN  A  One  Per  Cent  Potassium  Hydrate  Solution.  (Microphotograph,  courtesy  of 
the  Journal  of  the  American  Medical  Associatio7i.) 

the  Iniman  body.  The  testicles  have  usually  been  infected,  and  in  many 
cases  large,  caseous  masses  in  which  the  budding  organisms  occur  abun- 
dantly have  developed.  After  the  injection  of  moderate  doses,  guinea 
pigs  have  been  ill  for  a  time,  and  have  then  recovered.  The  best  results 
for  the  purposes  of  demonstrating  i)athologieal  findings  witli  the  organ- 
ism have  been  obtained  by  giving  large  doses  and  then  killing  the  ani- 
mal about  three  weeks  afterward. 
26 


390  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

Infection  Atrium. — In  some  of  the  cutaneous  cases  a  history  of  pre- 
ceding trauma  could  be  obtained.  This  apparently  opened  the  way 
for  infection.  In  the  majority  of  the  systemic  cases,  the  lungs  have 
been  accepted  as  the  point  of  origin  of  the  infection. 

It  is  an  interesting  fact  that  during  the  post-mortem  examination 
of  the  case  reported  by  Ormsby  and  i\Iiller,  one  of  the  attendants  was 
infected  Avith,  and  later  developed  blastomycosis,  this  case  being,  with- 
out question,  one  of  direct  inoculation.  In  only  one  instance  is  there 
a  record  of  more  than  one  case  occurring  in  a  family.  Three  members 
are  reported  with  the  disorder  by  Eastman  and  Keene. 

Comparison  between  Blastomycosis  and  Coccidioidal  Disease. — A 
group  of  cases  have  been  described  under  the  title  of  protozoic  dis- 
ease, protozoic  dermatitis,  dermatitis  coccidioides,  and  granuloma  cocci- 
dioides. 

The  first  was  recorded  by  Wernicke,  of  Buenos  Ayres,  as  a  doubtful 
mycosis  fungoides.  The  second  and  third  cases  were  studied  and  re- 
ported by  Rixford  and  Gilchrist.  Others  have  been  recorded  by  D.  W. 
Montgomery,  Rykfogel,  IMorrow,  Ophiils,  and  Moffett.  In  a  recent  report 
(October,  1905),  with  a  review  of  the  cases,  Ophiils  collates  ten  recorded 
and  adds  three  new  cases,  making  a  total  of  thirteen. 

This  disease  resembles  very  closely  blastomycosis,  both  clinically  and 
microscopically.  The  protozoic  disease  is  caused  by  an  organism  that 
resembles  in  many  particulars  the  germ  of  blastomycosis.  The  organ- 
ism found  in  the  California  cases  is  large,  circular,  double-contoured, 
and  develops  in  tissues  by  endogenous  spore-formation.  It  varies  in 
size  from  15  to  30  /*  in  diameter  and  contains  sporules,  sometimes 
as  many  as  a  hundred  in  a  single  capsule,  which  escape  upon  rupture 
of  the  capsule  and  develop  into  adult  forms. 

Prickles  or  long  spines  are  described  covering  the  capsule.  On 
media  the  organism  grows  as  a  mold  fungus.  Like  blastomycosis,  it 
produces  lesions  in  skin  and  in  internal  organs  resembling  tuberculosis. 
The  cutaneous  lesions  are  granulomatous  and  may  appear  as  papulo- 
pustules, ulcers,  tumors,  etc.  Cutaneous  lesions  may  precede  the  gen- 
eral infection,  or  be  secondary,  as  in  blastomycosis.  The  cases,  as  a 
rule,  have  been  fatal.  The  majority  of  the  cases  have  been  reported 
from  California.  Since  a  more  extended  study  has  been  made  of  the 
generalized  cases  of  blastomycosis,  the  early  differences  thought  to  exist 
between  the  two  disorders  have  been  reconciled.  At  present  the  only 
constant  difference  is  found  in  the  mode  of  reproduction  of  the  two 
organisms  in  tissue,  the  one  by  budding,  the  other  by  endogenous  spore- 
formation.  On  media,  too,  many  differences  may  be  pointed  out,  but 
tlif'sc  differences  are  no  greater  than  those  observed  between  different 
cultures  of  undoubted  blastomycetes.     It  is  maintained  by  D.  W.  Mont- 


BLASTOMYCOSIS  391 

gomery  that  potassium  iodic!  has  little  or  no  effect  either  in  the  cure  of 
or  inhibition  of  the  progress  of  coccidioidal  disease,  while  there  is  no 
question  as  to  its  value  in  blastomycosis.  It  seems,  therefore,  that  with 
so  many  points  of  resemblance,  and  with  so  few  differences,  the  two 
diseases  should  be  classed  as  members  of  the  same  group.  It  is  justi- 
fiable to  assume  that  climatic  differences  play  a  part.  One  patient  suf- 
fering from  generalized  blastomycosis  made  a  complete  recovery  on 
going  to  California,  but  large  doses  of  potassium  iodid  were  admin- 
istered for  a  long  period  before  leaving  Chicago   (Garvy). 

Diagnosis. — Tuberculosis  is  the  disease  w^hich  is  most  apt  to  be  con- 
fused with  systemic  blastomycosis.  In  one  case,  recorded  several  years 
ago,  the  diagnosis  of  tuberculosis  was  made  both  clinically  and  at  au- 
topsy. It  has  been  the  aim  during  the  developmental  period  of  the  stud- 
ies of  the  disease  to  positively  exclude  the  presence  of  the  bacillus  of 
tuberculosis.  In  two  cases,  in  the  study  of  which  the  writer  was  inter- 
ested, tuberculin  injections  were  made  with  negative  results.  Guinea 
pigs  were  inoculated  with  pus  from  cutaneous  and  subcutaneous  le- 
sions, and  also  with  tissue  and  tubercles  from  internal  organs,  always 
with  negative  results  as  far  as  tubercle  bacilli  were  concei-ned.  Large 
niunbers  of  smears  from  various  areas,  as  well  as  sections  of  tissue  from 
the  same  areas,  were  examined  for  tubercle  bacilli  with  negative  results. 
The  only  parasite  found  microscopically,  experimentally,  and  culturally 
was  the  organism  of  blastomycosis. 

In  any  case  of  doubtful  general  tuberculosis  the  si)utum,  as  well  as 
pus  from  the  cutaneous  or  subcutaneous  lesions,  should  be  examined 
for  blastomycetes. 

The  cutaneous  cases  have  been  mistaken  most  often  for  verrucous 
tuberculosis,  less  often  for  syphilis,  and  occasionally  for  epithelioma. 

The  chief  points  of  diff'erence  between  blastomycosis  and  verrucous 
tuberculosis  are:  In  blastomycosis  the  edge  of  the  patch  is  more  in- 
liannnatory  and  contains  the  characteristic  miliary  abscesses,  from 
which  the  organisms  can  be  readily  removed,  examined  in  a  ten  per 
cent  solution  of  potassium  hydrate,  and  be  readily  seen.  There  are 
apt  to  be  several  patches,  and  these  develop  with  great  rapidity.  In 
verrucous  tuberculosis  the  site  of  election  is  often  the  dorsum  of  the 
hand  alone,  while  in  blastomycosis,  if  this  region  be  involved,  other 
areas  also,  such  as  the  face  near  the  eyelid,  are  likely  to  be  affected. 
In  case  of  doubt  a  histological  section  reveals  the  true  nature  of  the 
process.  Miliary  abscesses  in  the  epidermis  and  the  corium,  containing 
leucocytes  and  blastomycetes,  make  the  diagnosis  positive.  Cultural 
experiments  also  may  be  made.  The  smooth,  supple  scar  of  l)lasto- 
mycosis  is  characteristic. 

The  late  lesions  of  syphilis  are  the  only  ones  that  could  possibly  be 


392  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

confused  with  the  lesions  of  blastomycosis.  The  circinate  lesions  of  lues, 
made  up  of  individual  tubercles  and  characteristic  ulcer-  and  scar-for- 
mation, differ  from  the  regular,  circular,  or  oval  patches  of  blastomy- 
cosis with  characteristic  edges,  miliary  abscesses,  etc.  The  latter  may 
persist  for  long  periods  in  the  same  area,  while  a  lesion  of  syphilis  is 
apt  to  heal  and  advance  to  new  areas.  The  microscope  should  be  used 
to  establish  the  diagnosis  when  there  is  doubt. 

Induration,  a  hard,  pearly  border,  and  the  absence  of  the  miliary 
abscesses  in  the  margin,  are  sufficient  to  differentiate  an  epithelioma 
from  a  blastomycotic  lesion. 

Technic  of  Examining  for  Blastomycosis  in  a  Given  Case. — The  bor- 
der is  cleansed;  then  with  a  clean,  sterile  needle  a  droplet  of  sero-pus 
is  removed  from  one  of  the  miliary  abscesses  and  placed  on  a  clean 
slide.  This  is  then  covered  with  a  drop  of  a  ten  per  cent  solution  of 
potassium  hydrate,  a  clean  cover  slip  placed  over  the  droj),  which  is 
examined  after  five  minutes  with  a  one  sixth  or  one  seventh  objective. 
The  double-contoured  and  usually  budding  organism  of  blastomycosis 
may  be  plainly  recognized  when  present. 

Prognosis. — Practically  all  cases  of  the  purely  cutaneous  type  recover 
in  time  under  proper  treatment.  Recurrences,  however,  are  common. 
Twelve  of  the  fifteen  patients  with  undoubted  general  blastomycosis 
have  died.  Only  one  has  apparently  entirely  recovered.  In  all  gener- 
alized cases,  therefore,  the  prognosis  is  grave. 

Treatment. — The  chief  remedial  agent  employed  successfully  is  po- 
tassium iodid,  first  advised  by  Dr.  Bevan.  This  drug  nearly  always 
produces  marked  results,  and  in  many  cases  has  entirely  cured  the  dis- 
ease. Doses  as  large  as  600  grains  per  diem  are  often  required.  It 
should  be  given  in  large  dilution.  It  may  be  gradually  increased,  as 
in  syphilis,  or  large  doses  in  large  dilution  may  be  given  early.  It 
should  be  administered  until  the  last  vestige  of  the  disease  disappears 
or  while  renewed  activity  occurs  after  its  withdrawal.  Radiotherapy  is 
of  value  in  completely  eradicating  small  resistant  areas.  More  recently 
Dr.  Bevan  has  ad^nsed  a  trial  of  copper  sulphate  in  one-quarter  grain 
doses  three  times  daily,  with  a  one  per  cent  solution  applied  as  a  wet 
dressing  locally,  with  good  results.  In  the  grave,  systemic  cases,  potas- 
sium iodid  has  exerted  only  iiihi])itory  effects,  except  in  one  case,  where 
it  apparently  had  much  to  do  with  the  recovery  of  the  patient.  It  is 
interesting  to  note  that  this  patient  recovered  under  large  doses  of 
potassium  iodid  and  a  change  of  residence  to  Cnlifoi-nia. 

In  cutaneous  cases  a  surgical  procedure  is  not  indicated  unless  the 
entire  lesion  can  be  excised.  Recovery  has  followed  complete  excision 
in  a  nnniltci'  (»("  locul  cases.  'Vhv  large  abscesses  and  other  lesions  occur- 
ring in  the  generalized  cases  reciuire  surgical  interference. 


TUBERCULOSIS  393 

Literature. — Gilchrist,  T.  C.  Johns  Hopkins  IIosp.  Rep.,  180f),  Vol.  L — 
Gilchrist-Stokes.  Bill,  of  Johns  Hopkins  Hosp.,  18'J6,  \'ol.  \'JL — Basse,  Otto.  Cent, 
f.  Bakt.  und  Parasitenk.,  18U4,  XVI,  p.  17.'). — Busse-Buschke.  Virchow's  Archiv, 
1895,  Vol.  CXL,  p.  23;  Verhandl.  der  Deutschen  Dermatologisehen  Gesellschaft,  Schester 
Congress,  1899,  p.  181.— Curtis.  Ann.  de  I'lnstit.  Pasteur,  1896,  Vol.  X,  p.  449. — Wells, 
H.  G.  N.  Y.  Med.  Jour.,  March  26,  1898.— /fessier,  Robert.  Ind.  Med.  Jour., 
1898,  Vol.  XVII,  p.  48. — Hyde,  Hektoen,  and  Bevan.  Brit.  Jour.  Dermatology,  1898, 
Vol.  XL — Hektoen.  Journ.  Experimental  Medicine,  1899,  Vol.  IV,  Xos.  3  and  4. — 
Owens,  Eisendruth,  and  Ready.  Annals  of  Surgery,  1899,  Vol.  XXX. — Murphy- 
Hektoen.  Journ.  A.  M.  A.,  1899,  Vol.  XXXIII,  p.  I'SSS.—Anthomj-Herzog.  Journ. 
Cut.  and  Gen.-Urin.  Dis.,  Jan.,  1900,  1. — Coates,  W.  E.  Medicine,  Feb.,  1900. — 
Baldwin,  L.  B.  Jour.  A.  M.  A.,  1900,  Vol.  XXXIV,  p.  292.— Brayton,  A.  TV.  Ind. 
Med.  Jour.,  April,  1900,  and  July,  1901;  Jour.  A.  M.  A.,  Feb.  1st,  1902. — Montgomery, 
'•Ricketts."  Jour.  C.  and  G.  U.  Dis.,  Jan.,  1901,  Vol.  XIX,  p.  26.— Dyer,  Isadore, 
Jour.  C.  and  G.  U.  Dis.,  Jan.,  1901. — Stelwagon,  H.  W.  Am.  Jour,  of  Med.  Sci.,  1901. 
Vol.  CXXI,  p.  176.— Harris,  F.  G.  Am.  Jour,  of  Med.  Sci.,  1901,  Vol.  CXXI,  p.  501.— 
Ormsby  and  Miller.  Jour.  Cutan.  Dis.,  March,  1903. — Cleary,  J.  H.  Trans.  Chicago 
Path.  Soc,  Vol.  XI,  No.  5,  May  9,  1904,  and  Medicine,  Nov.,  l<dQ^.—Eisendrath  and 
Ormsby.  Jour.  A.  M.  A.,  Oct.,  1905. — LeCount  and  Meyer.  Jour.  Infect.  Dis.,  1907. 
Vol.  IV,  No.  2.~Bassoe,  Peter.  Jour.  Infect.  Dis.,  1906,  LLL,  p.  91;  Trans.  Chic.  Path. 
Soc,  Vol.  VI,  No.  10,  p.  380.— 7ro/is,  E.  E.,  and  Graham,  E.  A.  Jour.  Infect.  Dis.,  1906, 
Vol.  Ill,  No.  4. — Christensen  and  Hektoen.  Jour.  A.  M.  A.,  July  28,  1906,  Vol.  XLVII, 
No.  4. —  Baum  and  Stober.  Demonstration  of  sections,  Chicago  Derm.  Soc,  Aj^ril, 
1907. — Garvy,  A.  C.  Demonstration  before  a  branch  of  Chicago  Med.  Soc,  May, 
1907. — Montgomery,  Frank  Hugh.  Case  demonstration  before  Chicago  Derm.  Soc, 
April,  1905.  Jour.  Cut.  Dis.,  1907,  Vol.  XXY.—Hyde  and  Montgomery.  Jour.  A.  M.A., 
June  7,  1902,  p.  1486,  Vol.  XXXVIII,  No.  23.— Ricketts,  Howard  T.  Jour.  Med.  Res., 
Vol.  VI,  No.  3.— Evans,  F.  J.  Jour.  A.  M.  A.,  June  27,  1003,  Vol.  XL,  No.  26.— 
Hamburger,  W.  W.  Jour.  Infect.  Dis.,  Vol.  IV,  No.  2,  1907.— 0^".s,  /•'.  J.,  and  Evans. 
Jour.  A.  M.  A.,  Oct.  31,  1903,  Vol.  XLI,  No.  IS.— Eastman,  J.  R.,  and  Keene,  T.  V. 
Annals  of  Surgery,  Vol.  XL,  No.  5,  Nov.,  1904. — Wernicke  (quoted  by  Gilchrist,  T.  C). 
—Rixford,  Emmett,  M.D.,  and  T.  C.  Gilchrist,  M.R.C.S.  (Eng.),  L.S.A.  (Lond.),  Johns 
Hopkins  Hosp.  Reports,  1896,  I,  209.— Ophuls,  W.  Jour.  Exper.  Med.,  Vol.  VI, 
Nos.  4,  5,  6. — Ophals,  W.,  and  Moffett,  H.  C.  Philadelphia  Med.  Jour.,  June,  1900. 
Ophids,  W.  Jour.  A.  M.  A.,  Oct.  28,  1905,  Vol.  XLV,  No.  18.— Montgomery,  D.  ^Y., 
Rykfoyel,  H.  A.  L.,  and  Morrow,  H.,  J.C.D.,  Vol.  XXI,  p.  5,  im'i.-Bevan,  A.  D.  Jour. 
A.  M.  A.,  Nov.  11,  1905. 


CHAPTER    X 

TUBERCULOSIS 

The  organism  now  known  as  the  tubercle  bacilhis  Avas  proven  ]\y 
R.  Koch  in  1882  to  be  the  cause  of  tuberculosis.  The  discovery  of  this 
organism  made  clear  a  number  of  pathological  changes  affecting  dif- 
ferent tissues  and  viscera,  and  made  possible  the  grouping  of  a  num- 
ber of  diseases  which  formerly  had  been  considered  to  be  separate 
and    distinct.      Undoubted    clinical    examples   have    convinced    us    that 


394  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

bovine  tuberculosis  may  be  transferred  to  man,  in  spite  of  the  fact 
that  Koch  (1901)  was  unable  to  infect  cattle  and  pigs  with  bacilli  of 
human  origin  and  expressed  his  belief  that  the  converse — i.  e.,  that  the 
bacillus  causing  bovine  tuberculosis  was  not  pathogenic  for  man — was 
true.  More  recent  investigations,  such  as  those  of  Kossel,  Weber,  and 
Heusz,  have  shown  that  there  are  slight  morphologic  and  cultural  dif- 
ferences between  the  human  and  bovine  types,  that  there  are  also  some 
differences  in  pathogenicity,  but  that  they  are  very  closely  related. 
Bovine  bacilli  are  more  virulent  for  most  mammals  than  are  human 
bacilli.  Cattle  are  not  susceptible  to  the  latter,  while  pigs  and  goats 
develop,  after  subcutaneous  injections,  a  chronic,  progressive  form  of  tu- 
berculosis. Rabbits  are  less  susceptible  to  the  human  than  to  the  bovine 
type.  There  is  no  marked  difference  in  pathogenicity  for  guinea  pigs. 
Von  Dungern  has  shown  that  the  same  results  follow  inoculation  and 
feeding  experiments  performed  upon  anthropoid  apes  with  these  two 
types  of  bacilli. 

The  practical  question  is  whether,  after  determining  the  differ- 
ences between  these  two  types  of  bacilli,  the  precautions  taken  against 
the  transmission  of  bovine  tuberculosis  to  man  are  superfluous.  Later 
investigations  have  shown  that  they  are  not.  Of  course,  the  human  type 
is  found  most  frequently  in  tuberculosis  as  it  occurs  in  man,  but  the 
bovine  type  is  found  also,  especially  in  children.  The  latter  type  is 
found  not  only  in  the  primary  tuberculosis  of  the  intestines  and  mesen- 
teric lymph  nodes,  but  also  in  the  peritonitis  which  follows,  in  the  vis- 
cera, in  the  miliary  forms,   and  even  in  some  cases  in  tuberculosis  of 

cervical  lymph  nodes,  of  the  joints,  and 
of  the  skin  following  injuries.     It  may 

/''  be  easily  seen  that  the  bovine  bacilli  are 

/  highly  significant  as  an  etiological  fac- 

/  |ft  ^         ^        tor  in  human  tuberculosis. 

^     'fllf  "0^   '  Bacillus  of  Tuberculosis. — Tubercle  ba- 


^^'     ^  «,'  I     cilli  are  non-motile,  often  slightly  curved, 


,    ^  '"  "^    -"*/      slender  rods  from  1.5  to  4  fj.  in  length. 

J        They    occur   singly    or    in    groups    and 

-'^         clusters  in  the  tissues,  and,  according  to 

the   present   view,    do   not   form   spores. 

In    animals    under    certain    conditions, 

Fig.    l.'j-l.         li    l:i   i;,   II       I'.ACII.I.I    IN  ,,  .        •      ^  1  1  , 

Fkk.su  Sputum.  ^^^^'Y    S^"''^^'    <^"t    into    longer    or   shorter 

branching  threads,  resembling  acti- 
nomyees  somewhat.  Friedrich  and  Nosske  observed  this  method  of 
growth  after  intra-arterial  injections  of  virulent  cultures. 

Resistance  of  the  Bacilli.— Tho  great  resistance  of  tubercle  bacilli 
cxphiiiis  llic  dirr<-icnt  modes  of  infection,  in  spite  of  the  fact  that  they 


TUBERCULOSIS  395 

do  not  grow  outside  of  the  body.  They  are  not  injured  by  drying 
or  cold,  and  withstand  212°  F.  of  dry  heat  for  some  hours.  In  the 
sputum  they  are  not  killed  by  chemical  agents,  as  they  are  surrounded 
by  mucus.  ]\Ioist  heat  at  a  temperature  of  203°  F.  kills  them  in  from 
one  to  two  minutes.  In  sputum  they  are  killed  by  boiling  for  five 
minutes. 

Cultures. — It  is  difficult  to  obtain  tubercle  bacilli  in  pure  culture, 
for  if  the  material  is  contaminated  the  other  micro-organisms  develop 
nnich  more  rapidly  and  overgrow  them.  Pure  cultures  are  most  easily 
obtained  by  transferring  fresh  tissues  or  a  slightly  caseated  focus  from 
an  infected  guinea  pig  to  blood  serum  or  glycerin-agar.  There  then 
develop  after  two  or  three  weeks  if  the  tubes  are  kept  at  a  temperature 
of  98.5°  to  100.5°  F.  with  free  access  of  air,  small,  white,  dry  scales, 
which  later  become  confluent  to  form  a  membrane.  Other  growths  upon 
ordinary  agar  and  bouillon  may  be  obtained  by  transplanting  this  pure 
culture. 

Experimental  Anwials. — The  guinea  pig  is  best  suited  for  experi- 
mental purposes,  as  it  develops  the  disease  most  rapidly  and  in  its 
severest  form.  An  animal  dies  in  from  ten  to  twenty  days  of  a  general 
tuberculosis  if  a  small  amount  of  tissue  containing  bacilli  or  a  pure 
culture  is  injected  into  the  peritoneal  cavity ;  after  some  weeks,  fol- 
lowing subcutaneous  injections,  localized  nodules  and  ulcers  having 
developed  in  the  meantime.  Rabbits  are  less  susceptible  and  die  of  a 
general  tuberculosis  only  after  intra-venous  or  intra-peritoneal  injec- 
tions. Tuberculosis  of  the  intestines,  mesenteric  lymph  nodes,  tonsils, 
and  cervical  lymph  nodes  have  followed  the  feeding  of  pure  cultures; 
tuberculosis  of  the  lungs,  the  inhalation  of  powdered  cultures;  and 
tuberculosis  of  bones  and  joints  (W.  INIiiller,  Friedrich),  the  injection 
of  bacilli  into  the  arterial  system  (femoral  artery,  aorta). 

Methods  of  Staining. — There  are  a  number  of  different  metluvls  for 
staining  tubercle  bacilli.  It  is  one  of  a  group  of  "  acid-fa.st  "  bacilli, 
and  does  not  readily  give  up  the  stain  which  it  takes.  Counter  stains 
may  be  used  and  the  bacillus  may  be  readily  diff'erentiated  from  the 
surrounding  tissues  and  associated  micro-organisms.  They  stain  not 
only  by  Gram's  method,  but  also  with  aniline  dyes,  if  an  alkali,  aniline 
oil,  or  carbolic  acid  is  added  and  the  stains  are  allowed  to  act  for  some 
time.  Other  micro-organisms  and  cells,  present  in  smears  or  tissues, 
may  be  destained  with  alcohol  or  acids. 

Examination  of  cultures,  exudates,  tuberculous  debris,  and  sputum 
are  made  in  the  following  way :  Thin,  even  smears  of  the  material  to  be 
examined  are  made  upon  cover  glasses.  1'he  covei-  glasses  ai"e  then 
passed  through  a  flame  two  or  three  times  until  the  smear  is  dry. 
Ziehl's  carliol-fuchsin  is   then   dropped   upon  the  cover  glass  until   the 


396  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

smear  is  thoroughly  covered.  The  cover  glass  is  then  gently  warmed 
until  steam  arises;  the  specimen  is  allowed  to  remain  in  the  hot  stain 
two  or  three  minutes,  and  is  then  washed  in  water.  The  other  bacteria 
and  cells  are  then  destained  by  placing  the  cover  glass  for  a  short  time 
in  twenty -five  per  cent  nitric  acid,  or,  better,  a  three  per  cent  solution  in 
hydrochloric  acid  in  alcohol.  After  washing  in  water  the  smear  is 
counterstained  with  a  dilute  a({ueous  or  alkaline  solution  of  methylene 
blue.  This  solution  is  then  removed  with  blotting  paper  and  the  prepa- 
ration is  again  washed  with  water.  Balsam  may  be  applied  to  a  well- 
dried  cover  glass  and  a  permanent  preparation  made. 

Staining  of  Bacilli  in  Tissues. — Ehrlich's  mixture  of  a  saturated 
aqueous  aniline  solution  with  an  alcoholic  solution  of  fuchsin  or  gen- 
tian, in  which  the  sections  should  remain  from  twelve  to  twenty-four 
hours,  and  Ziehl's  solution  are  to  be  recommended  for  staining  the 
bacilli  in  tissues.  After  washing  they  should  be  destained  in  a  three 
per  cent  solution  of  hydrochloric  acid  in  alcohol,  or  in  a  twenty-five 
per  cent  solution  of  nitric  acid  and  placed  in  sixty  per  cent  alcohol. 
They  should  then  be  washed  in"  water  a  number  of  times  to  remove  the 
acid,  and  counterstained  with  methylene  blue  or  Bismarck  brown. 

Liiferences  between  the  Bacilli  of  Tuberculosis  and  of  Leprosy  and 
Smegma  Bacilli. — For  the  method  of  differentiating  the  bacilli  of  tuber- 
culosis and  leprosy,  vide  page  448.  The  tubercle  bacillus  may  be  mis- 
taken for  the  smegma  bacillus  (e.g.,  in  examinations  of  the  urine). 
Cornet  recommends  Weichselbaum 's  method  for  differentiating  between 
tubercle  and  smegma  bacilli.  Stain  with  carbol-fuchsin,  then,  without 
destaining,  use  a  concentrated  solution  of  methylene  blue  in  absolute 
alcohol.  The  tubercle  bacilli  remain  red,  the  smegma  bacilli  become 
blue.  Animal  inoculation  is,  of  course,  the  surest  and  most  satisfactory 
method  of  differentiating  between  the  two. 

The  difference  in  virulence  of  tubercle  bacilli  from  different  sources 
and  during  cultivation  (decrease  of  virulence  when  growing  upon  me- 
dia, and  increase  when  passed  through  animals)  depends  upon  the  dif- 
ference in  the  toxin-content  of  the  bacilli   (von  Behring). 

Toxins. — According  to  von  Behring,  toxins  are  found  in  the  culture 
media  and  in  the  pi-otophism  of  the  bacilli.  The  latter  (endotoxins)  pro- 
duce, when  dead  l)acilli  are  injected  into  animals,  inflammation,  sup- 
puration, and,  when  a  thick  emulsion  is  injected  intravenously,  tuber- 
culouslike  changes  in  the  tissues  (Koch,  Masur,  Kockel,  and  others). 

Different  toxic  substances  are  found  in  the  residue,  which  contains 
bacilli,  obtained  by  the  filtration  of  cultures.  Koch  prepared  his  tuber- 
culin by  making  a  glycerin  extract  of  this  residue.  Von  Behring  ana- 
lyzed this  residue  into  separate  substances,  the  end  product  of  which, 
tuhcrculosin,  he  regards  as  the  active  and  specific  toxic  base. 


TUBERCULOSIS  397 

Immunization  of  Animals — Tuberculin-R. — Kooli  with  his  tuborcn- 
liii  was  the  first  to  attempt  to  ijiiiiuinize  aiiiiuals  against  tuberculosis 
and  to  cure  animals  already  diseased.  Tuberculous  guinea  pigs  treated 
with  tuberculin  remained  alive  longer  than  conti'ol  animals  which  were 
not  treated  (Pfuhl,  Kitasato),  but  the  animals  never  recovered,  as 
Koch  in  the  beginning  thought  possible.  Tuberculin  has  not  proven  to 
be  of  any  great  value  as  a  therapeutic  measure.  The  changes  in  the  local 
condition  and  the  general  reaction  which  follow  its  injection  in  tubercu- 
lous subjects  make  it  very  valuable  for  diagnostic  purposes,  although 
dangerous  exacerbations  and  collapse  may  follow  its  use.  It  is  used  for 
diagnostic  purposes,  especially  in  cattle.  When  finally  no  reaction  fol- 
lows the  use  of  tuberculin,  because  of  immunization  against  it,  the  tu- 
berculous process  may  extend  or  develop  anew.  The  immunity  which  is 
established  against  tuberculin  has  no  effect  whatever  upon  the  develop- 
ment and  growth  of  the  bacilli.  In  order  to  produce  an  immunity 
against  the  bacilli,  Koch  prepared  his  Tuberculin-R.  [Tuberculin-R.  is 
made  in  the  following  way:  "  Dried  ma.sses  of  the  oi'ganism  are  ground 
up  in  an  agate  mortar.  After  suspension  in  distilled  water  and  cen- 
trifugation,  the  emulsion  consists  of  two  layers.  The  overlying,  opa- 
lescent, whitish  fluid  is  designated  as  '  T.  0.'  (Tubereulin-Obers). 
After  the  removal  of  the  fluid  from  the  precipitate  the  latter  was  again 
dried  and  ground,  suspended  in  water  and  centrifugated  as  before, 
and  the  process  repeated  until  none  of  the  sediment  remained.  The 
different  fractions  of  fluid,  except  the  '  T.  0.'  were  combined  to  con- 
stitute '  T.  R.'  (Tuberculin-Rest),  which  is  really  an  enuilsion  of 
minute  fragments  of  bacilli." — Ricketts,  "  Infection,  Immunity,  and 
Serum  Therapy,"  p.  413.]  The  pyogenic  substances  are  removed  by 
precipitation  and  then  the  tuberculin  is  rapidly  absorbed  and  no  ab- 
scesses form. 

A.  Wasserman  and  Bruck  attempt  to  explain  llie  occurrence  or 
absence  of  the  tuberculin  reaction  in  the  following  way:  According  to 
their  investigations,  antituberculin  is  formed  in  tuberculous  foci  (local 
immunity),  and  the  tuberculin  injected  into  the  body  is  attracted  to 
the  tuberculous  foci  by  these  antibodies.  The  complement  is  bound 
when  the  tuberculin  unites  with  its  antibody  and  there  is  a  local  accii- 
mulation  of  ferments  which  liquefy  the  tissues  and  produce  softening 
of  the  diseased  foci.  There  is  no  local  reaction,  likewise  no  general  re- 
action, when,  as  a  result  of  tuberculin  treatment,  antibodies  are  found 
in  the  blood;  then  the  latter  become  bound  to  the  tuberculin  in  the  cir- 
culating blood,  and  the  tuberculin  is  prevented  from  reaching  the  tuber- 
culous foci.  Von  Behring  (1902)  successfully  innnunized  cattle  with  the 
human  type  of  bacillus,  not  dangerous  for  cattle,  against  bovine  tuber- 
culosis.    Just  as  Jenner  succeeded  in  innnunizing  man   against  small- 


398  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

pox  by  inoculating  him  with  cowpox,  so  von  Behring  was  able  to  inoculate 
cattle  with  the  human  bacillus  and  render  them  immune  against  infec- 
tion with  bovine  tuberculosis  (therefore,  Jennerization).  The  results 
obtained  by  von  Behring  have  been  confirmed  by  Baumgarten. 

Modes  of  Infection. — Infection  may  follow  the  inhalation  of  dust 
or  particles  laden  with  bacilli,  the  ingestion  of  infected  food,  or  the 
inoculation  of  wounds  or  ulcers.  The  disease  has  been  transferred 
from  a  diseased  mother  to  the  fcptus. 

Whether  the  disease  develops  or  not  after  the  bacilli  have  been  in- 
troduced depends  upon  the  number  and  virulence  of  the  bacilli  and 
the  resistance  of  the  patient. 

Pulmonary  tuberculosis  is  the  most  common  form  of  the  disease  in 
man.  It  may  follow  directly  the  inhalation  of  the  bacilli  or  may  be 
secondary  to  a  tuberculosis  of  lymph-nodes.  Normally  the  upper  re- 
spiratory passages  are  protected  from  infection  by  their  mucous  secre- 
tion, and  for  this  reason  are  much  more  rarely  involved  than  the  lower. 
The  sputum  of  a  tuberculous  patient  carries  with  it  the  greatest  dangers 
of  infection  in  tliis  form  of  tuberculosis.  Bacilli  are  also  found  in  the 
secretion  of  tuberculous  ulcers,  and  are  discharged  into  the  outer  world 
in  the  faeces  and  urine  of  tuberculous  patients,  but  infection  from  these 
sources  is  not  as  common  as  that  from  the  sputum.  The  sputum,  unless 
proper  precautions  are  taken,  later  dries  upon  the  floor  or  pocket  hand- 
kerchiefs, is  pulverized  and  mixed  with  the  air.  Attempts  have  been 
made  to  educate  the  public  not  to  spit  upon  the  floors  of  large  assembly 
halls,  but  into  spittoons  containing  water,  in  order  to  prevent  the  dan- 
gers of  infection  (Cornet).  The  air  about  tuberculous  patients  may  be 
infective,  as  small  drops  of  fluid  which  contain  bacilli  are  discharged 
when  the  patient  coughs.  The  possibility  of  infection  by  the  inhalation 
of  both  dried  and  moist  tuberculous  sputum  has  been  demonstrated  ex- 
perimentally (Cornet,  Fliigge). 

Tuberculosis  of  the  gastro-intestinal  tract  may  follow  the  ingestion 
of  infected  food  and  drink  and  the  swallowing  of  tuberculous  sputum. 
The  pernicious  habit  some  mothers  have  of  licking  the  artificial  nipple 
used  upon  the  nursing  bottle,  and  of  chewing  the  bread  before  giving 
it  to  the  child  is  a  source  of  danger  in  this  form  of  tuberculosis.  The 
milk  of  cows  suffering  from  a  general  tuberculosis  or  a  tuberculosis 
of  the  udder  is  rich  in  bacilli,  and  may  cause  an  intestinal  tuberculosis. 
There  is  also  danger  of  infection  fi-om  eating  meat  from  tuberculous 
cattle  which  is  imperfectly  cooked,  and  butter  made  from  milk  contain- 
ing the  bacilli.  Roger  and  Garnier  have  demonstrated  that  the  milk 
of  a  nui'sing  mother  may  contain  bacilli  even  when  there  is  no  disease 
of  the  l)i'cast,  and,  l)esides,  the  excreta  of  a  tuberculous  mother  are 
always  the  source  of  grave  danger  to  the  child. 


TUBERCTTLOSIS  399 

Finally,  tiibL-rclc  bacilli  may  be  do})().sit(>cl  upon  recent  and  old 
wounds,  gangrenous  areas,  anti  ideers.  Bacilli  may  gain  access  to 
wounds  of  the  hands  during  operations,  post-mortem  examinations,  the 
slaughtering  of  diseased  cattle,  or  the  milking  of  cows  with  tuberculous 
udders,  and  they  may  be  carried  on  the  hands  to  other  parts  of  the 
body.  Small  wounds  of  the  skin  (scratches)  or  ulcers  (ulcus  cruris) 
may  become  infected  in  this  way.  Infection  may  follow  an  injury  pro- 
duced by  an  instrument  or  foreign  body  to  which  bacilli  were  attached. 
Occasionally  infection  may  follow  a  fall,  but  this  is  rare,  as  the  dust 
of  the  street,  unless  it  contains  fresh  tuberculous  sputum,  is  free  from 
tubercle  bacilli  (Cornet).  Secondary  infection  of  a  wound,  because 
improperly  treated  (use  of  court  plaster  moistened  with  sputum, 
washing  out  and  bandaging  with  infected  handkerchiefs),  is  much  more 
frequent.  Tuberculosis  of  circumcision  wounds,  following  attempts  by 
a  tuberculous  rabbi  to  control  hannorrhage  by  sucking  the  bleeding 
surfaces,  belongs  to  this  class  of  infections. 

Transmission  of  tuberculosis  from  the  mother  to  the  foetus  is  pos- 
sible (placental  infection).  Friedmann's  experiments  show  that  tuber- 
cle bacilli  may  pass  with  the  spermatozoa  into  the  ovum  (conceptional 
and  germinal  transmission).  Tuberculosis  should  be  supposed  to  be 
of  congenital  origin  only  when  it  develops  in  the  newborn,  as  older 
children  living  with  tuberculous  parents  have  been  exposed  since  birth 
to  infection.  Experience  shows  that  the  children  of  tuberculous  pa- 
tients are  more  susceptible  to  tuberculosis  than  the  children  of  non- 
tubereuhms  patients  (hereditary  predisposition),  and  also  that  those 
whose  nutrition  is  not  good  or  who  have  been  weakened  by  iinn-ions 
disease  are  especially  susceptible  (acquired  predisposition). 

Histology  of  the  Tubercle. — When  tubercle  bacilli  are  deposited  in 
tissues  they  nuiltiply  slowly  and  incite  a  number  of  tissue  changes. 
These  begin  with  a  degeneration  of  surrounding  connective  tissues  and 
cells.  This  degeneration  is  then  followed  by  a  proliferation  of  the 
healthy  connective  tissue  cells  and  the  immigration  of  leucocytes  into 
the  area  involved.  Small  grayish,  cellular  nodules,  to  wliich  the  name 
of  tubercle  has  been  given,  are  formed.  Virchow  (1852)  suggested 
that  the  term  tuhcrde,  which  before  had  had  a  general  application,  be 
applied  only  to  this  pathological  change.  The  tubercles,  which  rarely 
become  larger  than  a  millet  seed,  comi)ose  the  tuberculous  granulation 
tissue  which  is  produced  by  the  proliferation  of  tissues  in  Mhich  the 
bacilli  are  deposited,  and  by  the  immigration  of  leucocytes.  Occasion- 
ally tuberculous  granulation  tissue  develops  without  tubercle  foi-mation. 

The  changes  occurring  in  the  tubercles  and  the  tuberculous  granu- 
lation tissue  determine  the  course  and  the  sequehr  of  the  disease. 

According   to    Baumgarten's    investigations,    the    connective    tissues 


400 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


and  the  endothelial  cells  of  the  blood  and  lymph  vessels,  sometimes  the 
epithelial  cells,  react  to  the  stimulus  of  the  tubercle  bacilli  and  their 
toxins  by  dividing  mitotically.  In  about  one  week  in  animal  experi- 
ments there  is  an  accumulation  of  large  cells  (epithelioid  cells)  which 
resemble  epithelial  cells  and  develop  mostly  from  fibroblasts.  Leuco- 
cytes in  different  numbers  wander  from  the  neighboring  vessels  into 
the  inflamed  area  (Fig.  155).     If  leucocytes  are  present  in  such  large 


Fig.  155. — Section  through  a  Tubercle.     Upon  the  margin  of  the  tubercle  lymphoid  cells 
may  be  seen;  in  the  center  epithelioid  cells  and  a  giant  cell. 


numbers  that  almost  nothing  can  be  seen  of  the  large  epithelioid  cells, 
one  speaks  of  a  small-cell  or  lymphoid  tubercle,  in  contradistinction 
to  a  large-cell  or  e])itlielioid  tubercle,  in  which  the  large  cells  resembling 
epithelial  cells  pi-edomiiiatt^.  The  old  connective  tissue  fibrils,  separated 
by  tlie  cellular  inliltration,  form  the  supporting  structure,  the  rcllcn- 
luni  of  the  tubcfcle.  In  the  center  of  the  tub(>rcle  there  ai-e  frequently 
found  one  or  more  multinuclear  giant-cells  (Langhans'  type)  in  which 
the  nuclei  have  a  polar  or  peripheral  arrangement.  (J roups  of  bacilli 
may  be  found  within  the  cytoplasm  of  these  cells.  It  is  supposed  that 
the  bacilli  stinnilate  nuclear  divisicm  in  these  cells,  and  that  the  failure 
of  cell  division  is  due  to  the  injiuy  of  the  eytoplnsm.  ["  Metschnikoff 
and  others  take  a  diCt'erent  view  of  the  formation  of  oiant-eells,  con- 


TUBERCULOSIS  401 

sidering'  that  they  represent  individual  epithelioid  cells  which  have 
fused  to  form  a  multinuciear  mass." — Ricketts,  "  Infection,  Immunity, 
and  Serum  Therapy."] 

Regressive  Changes  in  the  Tubercle. — The  fully  developed  tubei-de, 
which  is  gray,  translucent,  and  may  be  as  large  as  a  millet  seed,  begins 
sooner  or  later,  under  the  toxic  action  of  the  bacilli,  to  degenerate  in 
the  center.  Round  cells,  fibroblasts,  and  giant-cells  gradually  degen- 
erate until  the  entire  tubercle  is  transformed  into  a  hyaline  (coagu- 
lation necrosis  of  Weigert),  finally  into  a  granular,  fatty  mass,  in  which 
the  bacilli  gradually  die.  The  caseated  tubercle  is  opaque  and  yellowish- 
white.  A  fibrous  capsule  is  formed  by  the  proliferation  of  the  sur- 
rounding connective  tissue  which  may  replace  entirely  or  partly  the 
degenerated  mass   (fibro-caseous  tubercle). 

The  tubercle  or  groups  of  tubercles  may  undergo  a  number  of  re- 
gressive changes.  The  tubercle  imbedded  in  the  tuberculous  granula- 
tion tissue  has  upon  section  the  appearance  of  a  spongy,  semitrans- 
parent,  grayish  red  (if  caseation  occurs,  yellowish)  mass.  Ulcers  and 
fistulas  follow  regressive  changes  in  tubercles  situated  near  the  surface 
of  the  body,  in  the  skin,  or  mucous  membrane.  Large  caseous  (if  the 
connective  tissue  proliferates,  fibro-caseous)  nodules  follow  the  degen- 
eration of  tubercles  situated  in  the  deeper  tissues  or  viscera.     If  the 


Fig.    156. — Tuukkculoi  s  (iiANT  Cells  Containing   a   Fkw    Ii  liiiKci.E  Bacilli. 

tubercles  become  softened  and  liquelied,  large  cavities  with  contents 
resembling  pus  (cavities  in  the  lung,  abscesses  in  lymph  nodes)  are 
formed.  The  extension  of  the  tuberculous  i)rocess  and  the  development 
of  tuberculous  (cold)  abscesses  follow  the  deposition  of  bacilli  in  sur- 
rounding tissues  and  the  development  of  new  nodules.  Gravity  and 
the  anatomical  arrangement  of  the  loose,  fascial  planes  are  important 
in  determining  the  direction  in  which  the  disease  extends  and  tuber- 
culous pus  burrows  (gravitation  abscess).  In  ulcers  of  the  skin  and 
mucous  membranes  the  tubercles  lie  exposed  in  the  pale,  Habby,  glassy, 
or  yellowish  granulations;  they  cover  the  synovial  membrane  in  tuber- 
culous arthritis,  and  are  found  in  the  walls  of  tuberculous  abscesses 
(Fig.  157). 


402 


WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 


Fig.  157. — Tuberculous  Abscess  Membrane. 


The  pathological  changes,  formation  of  graniUation  tissue,  caseation, 
suppuration,  or  encapsuhition,  vary  in  the  different  forms  of  tuber- 
culosis.    The  virulence  of  the  bacilli  and  the  resistance  of  the  tissues 

determine  whether  the 
tuberculous  foci  will  cic- 
atrize, caseate,  or  sup- 
purate. The  first  form, 
which  Konig  has  called 
the  dry  tuberculous 
g  r  a  n  u  1  a  t  i  o  n  tissue,  is 
much  more  benign  than 
the  caseating  form.  This 
difference  in  clinical 
course  seems  to  depend 
upon  whether  small  or 
large  amounts  of  toxins 
are  formed.  In  tuber- 
culosis of  the  serous  cavi- 
ties and  joints,  the  pathological  processes  are  still  more  complicated, 
as  a  serofibrinous  exudate  is  formed. 

Secondary  Infection. — If  a  tuberculous  focus  becomes  infected  with 
pyogenic  bacteria,  through  the  blood  or  a  fistula,  an  acute  inflammation 
develops  and  a  purulent  exudate  is  formed  as  the  result  of  the  second- 
ary pyogenic  infection. 

Tuberculous  Pus. — Tuberculous  pus,  the  result  of  liquefaction  of 
caseous  material,  differs  from  that  formed  in  suppurative  inflammations 
caused  by  pyogenic  bacteria.  As  the  caseous  material  liquefies,  it  be- 
comes mixed  with  a  serous  or  serofibrinous  exudate.  Tuberculous  pus 
is  watery,  white  or  light  green  in  color,  and  contains  masses  of  caseous 
material,  strings  and  flakes  of  fibrin.  On  the  other  hand,  pus  formed 
in  suppurative  inflammations  is  thick  and  creamy,  as  the  solid  par- 
ticles are  evenl}^  distributed  throughout  its  substance.  Pus  corpuscles 
in  tuberculous  lesions  early  undergo  fatty  degeneration  and  disinte- 
grate (Tavel),  so  that  but  few  are  found  when  the  pus  is  examined 
microscopically.  Tubercle  bacilli  are  not  numerous,  and  it  may  be 
impossible  to  demonstrate  them  by  microscopical  examination.  Often 
it  is  necessary  to  resort  to  animal  inoculations  to  determine  the 
character  of  pus  removed  from  doubtful  lesions.  The  liquefaction  of 
tuberculous  nodules  and  infiltrations  is  due  to  the  action  of  poly- 
morpho-nuclear  leucocytes,  and  not  to  that  of  tubercle  bacilli  or 
pyogenic  bacteria.  When  the  leucocytes  disintegrate  ferments  are  set 
free,  which  digest  and  liquefy  the  necrotic,  caseous  material  (Friedrich 
IMuller). 


TUBERCULOSIS  403 

A  local,  limited  tiiberculo.sis  is  dil't't'i'i'iiliated  I'roiu  a  general  miliary 
tuberculosis,  which  develops  from  the  former.  The  majority  of  the 
lesions  developing  in  localized,  limited  tuberculosis  are  treated  sur- 
gically. 

LOCAL  SURGICAL  TUBERCULOSIS 

The  foci  may  develop  in  the  infection  atria  or  in  the  parts  where 
the  bacilli  are  deposited  by  the  blood  and  lymph  streams. 

(a)  TUBERCULOSIS   OF  THE  SKIN 

The  Anatomical  Tubercle. — The  so-called  "  anatomical  tubercle  " 
may  develop  upon  the  hands  of  individuals  who  work  with  tuberculous 
materials  from  man  or  cattle,  following  an  injury  of  the  skin.  A 
small,  firm,  reddish  brown  nodule,  which  may  become  as  large  as  a  pea, 
develops  at  the  point  of  injury  after  some  weeks.  It  is  covered  with  a 
cornified,  fissured  epidermis,  and  often,  after  lasting  for  some  time, 
disappears  spontaneously.  The  "  anatomical  tubercle  "  is  the  most 
benign  form  of  tuberculosis  of  the  skin.  It  does  not  ulcerate,  and  onlj' 
rarely  is  it  followed  by  involvement  of  glands  about  the  elbow.  >\lixed 
infections  occur  frequently. 

Verrucous  Tuberculosis  of  the  Skin. — According  to  Riehl  and  Pal- 
tauf,  verrucous  tuberculosis  of  the  skin  (tuberculosis  cutis  verrucosa) 
is  a  form  of  tuberculosis  which  also  follows  injuries  of  the  skin.  The 
flat,  slightly  elevated,  usually  round,  infiltrated  area  has  a  bluish  red 
border  and  an  irregularly  warty  surface.  It  pursues  a  chronic  course, 
and  the  infiltrated  area,  without  ulcerating,  becomes  as  large  as  a  silver 
dollar  or  may  finally  involve  the  dorsum  of  the  hand  and  a  part  of 
the  forearm.  The  hands  are  most  frequently  attacked,  especially  in 
such  people  as  butchers  and  those  who  come  in  contact  with  materials 
from  tuberculous  cattle.  A  case  in  von  Bergmann's  clinic  followed  an 
injury  of  the  dorsum  of  the  hand  with  a  milk  pail.  The  epitrochlear 
and  axillary  lymph  nodes  may  be  involved  after  the  skin  lesion  has 
persisted  for  some  time. 

Tuberculous  ulcers  of  the  skin,  excepting  those  developing  in  lupus 
exulcerans,  are  most  often  secondary  to  a  tuberculosis  of  the  nnicous 
membranes  of  the  mouth,  rectum,  and  genitalia.  The  process  as  a  rule 
extends  from  the  mucous  membrane  to  the  skin.  These  ulcers  usually 
develop  in  the  terminal  stages  of  some  of  the  other  forms  of  the  disease 
from  small  miliary  nodules  which  form  in  the  skin.  The  ulcers  are 
characterized  by  flat,  irregular,  undermined  borders,  and  by  pale, 
translucent,  yellowish,  soft  granulations  which  may  be  easily  wiped 
away  with  little  hremorrhage  with  gauze. 

It  has  already  been  mentioned  that  the  wounds  following  circum- 


404 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


cision  in  young  Jewish  cliildren  may  be  infected,  as  a  result  of  the 
sucking  of  the  wound  by  a  tuberculous  rabbi.  Small  nodules  then 
develop  in  the  prepuce,  which  later  ulcerate  and  lead  to  the  formation 
of  chronic  ulcers.  After  some  weeks  the  inguinal  lymph  nodes  become 
involved;  general  glandular  and  miliary  tuberculosis  have  been  ob- 
served. 

Lupus. — Tuberculosis   of  the  skin   develops   most  frequently   in  the 
form  of  small  brownish  red  macules  or  slightly  elevated  nodules,  which 

are  sometimes  hard.  The 
nodules  may  be  of  pin- 
head  size  or  may  become 
as  large  as  a  pea.  The 
color  of  the  nodule  dis- 
appears but  little  when 
pressure  is  made;  this  is 
an  important  diagnostic 
sign.  They  develop  in  all 
layers  of  the  cutis,  fre- 
quently also  in  the  sub- 
cutaneous fat,  and  corre- 
spond to  the  miliary 
tubercles  or  to  a  number 
of  the  same.  They  may 
be  single  or  multiple,  and 
the  area  of  skin  involved 
may  be  very  circumscribed 
or  extensive. 

The  face  is  most  fre- 
quently affected  in  this 
form  of  cutaneous  tuber- 
culosis, the  so-called  lupus.  In  100  cases  the  disease  attacked  the  face 
76  times,  and  of  the  76  cases  the  nose  was  affected  in  38.  The  skin  of 
the  extremities  is  attacked  relatively  frequently.  The  development  of 
lupus  nodules  has  been  observed  after  inoculation  of  the  skin  with 
tubercle  bacilli — e.  g.,  after  the  use  of  saliva  in  tattooing.  There  are 
a  number  of  cases  in  which  the  ectogenous  infection  of  an  already  dis- 
eased area  of  skin  (eczema)  has  been  demonstrated.  According  to 
Cornet  it  is  not  essential  that  the  skin  be  injured,  for  tubercle  bacilli, 
like  staphylococci,  mjiy  be  forced  into  the  hair  follicles  and  deeper 
tissues  by  rubbing  (e.  g.,  wiping  the  nose  with  an  infected  handker- 
chief). Of  course  the  bacilli  may  be  carried  in  the  patient's  sputum, 
and  the  skin  about  the  mouth  may  become  infected  from  it.  The  skin 
sun-ounding   a  tuberculous  fistula  or  covering  a  caseated   lymph  node 


.-if^/:!:S 


\ 


Fig.   158. 


-Lupus  Exulcerans  and  Exfoliativus 
Faciei. 


TUBERCULOSIS 


405 


or  a  tnbercnloiis  focus  in  a  bone,  may  become  seeondarily  involved. 
Tiiliercles  may  develop  at  the  mueo-eutaneous  margins  (lips,  nose,  and 
anus).    The  infections  at  these  places  may  develop  from  the  lymphatics, 


FiQ.    159. — Cutaneous   Tuberculosis    (Lupus   Faciei).     Tubercles   may    be   seen    in   the 

subcutaneous  fat. 


or  may  be  the  result  of  direct  infection  with  the  secretions  which  con- 
tain bacilli.  The  classical  form  of  Inpns  of  the  face  is  fretiuently 
secondary  to  a  hipns  of  the  nasal  mncons  membrane.  It  begins  in 
the  nose  and  then  extends  to  the  skin  of  the  nose,  upper  lip,  and  both 

27 


406 


WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 


cheeks,  producing  the  well-known  "  butterfly-shaped  "  lesion.  Some- 
times tuberculosis  develops  in  the  scar  resulting  from  extensive  opera- 
tions for  tuberculosis  of  bone  (e.  g.,  joint  resection),  and  sometimes 
in  these  cases  bacilli  are  carried  into  the  skin  during  the  operation; 
at  other  times  the  wound  is  infected  by  the  secretion  discharged  during 
the  repair  of  the  wound.  As  compared  to  the  ectogenous  and  lymphog- 
enous infections,  ha^natogenous  infections  are  rare. 

Different  Clinical  Pictures. — Tuberculosis  of  the  skin  presents  dif- 
ferent clinical  pictures,  depending  upon  the  area  of  skin  involved,  the 
size  of  the  nodule,  and  whether  the  i>rogressive  or  regressive  predomi- 
nate. Sometimes  the  nodules  disappear  spontaneously  and  healing 
occurs ;  sometimes  the  nodules  ulcerate ;  at  other  times  the  tissues  hyper- 
trophy, producing  large  disfiguring  growths.  The  following  forms  of 
lupus  are  described:  Disseminated  lupus  (lupus  disseminatus),  in  which 
single  nodules  are  scattered  throughout  the  area  involved;  serpiginous 
lupus  (lupus  serpiginosus),  in  which  the  nodules  are  close  together 
and  arranged  in  the  form  of  a  curve;  exfoliating  lupus  (lupus  exfoli- 

ativus),  with  exfoliation  of 
the  skin,  extrusion  or  ab- 
sorption of  the  caseated  tu- 
bercle, and  subsequent  heal- 
ing; ulcerating  lupus  (lupus 
exulcerans),  in  which  the 
larger  nodules  ulcerate, 
forming  shallow  ulcers,  the 
process  often  extending  at 
the  periphery,  while  the  cen- 
ter heals,  deformities  of 
the  face,  toes,  and  fingers 
following  the  cicatricial 
changes;  hypertrophic  lu- 
pus (lupus  hypertrophicus), 
in  which  there  is  a  marked 
growth  of  the  cutaneous  and 
subcutaneous  connective  tis- 
sues (occurring  particularly 
upon  the  lobule  of  the  ear)  ; 
papillary  or  verrucous  lu- 
pus (lupus  papillaris  or  ver- 
rucosus), resulting  from  a  growth  of  the  papilla^  of  the  skin;  and  lupus 
cornutus,  in  which  the  epidermis  becomes  cornified. 

Clinical  Course  of  Lupus. — The  clinical  course,  of  lupus  is  chronic. 
Frefiuctitly    (in   eighty-five   per    cent    of   the    cases)    tuberculous   foci 


Fig.  160. — IIvPEKrmji'Hic  and  ITlcerating  Lupus 
Healing  after  excision  of  lesion  and  transplan- 
tation of  a  large  cutis  graft  from  the  tliigli. 


TUBERCULOSIS 


407 


develop  in  the  viscera,  bones,  or  joints.  The  process  subsides  for 
a  time  in  the  skin  involved,  and  then  develops  again,  this  process 
occurring    repeatedly    in    the    course    of    the    disease.      The    caseated 

nodules  are  absorbed  or  extruded  and  are 
replaced  by  scar  tissue,  but  soon  new  tuber- 
cles develop  in  the  scar  or  in  the  tissues  sur- 
rounding it.  The  mildest  cases  are  those 
in  which  the  nodules  do  not  coalesce  and 
do  not  ulcerate.  If,  on  the  other  hand,  large 
areas  of  skin  become  infiltrated,  deep  ulcers 
may  develop  and  large  disfiguring  scars  may 
subsequently  form.  These  scars  produce  the 
worst  cosmetic  and  functional  results  when 
they  involve  the  face,  the  fingers,  and  the 
toes.  Scars  upon  the  face  may  produce 
an  ectropion  of  the  lids  or  lips,  a  narrow- 
ing of  the  mouth,  adhasions  about  the  en- 
trance to  the  nose.  Lupus  about 
the  nose  may  destroy  the  al^e  nasi 
with  their  cartilages.  The  concha 
may  be  destroyed  in  the  same 
way.  Scars  upon 
the  fingers  and 
toes  may  pro- 
duce contrac- 
tures which  de- 
stroy completely 
the  function  of 
the  digits. 
The  lymph  nodes  adjacent  to  the  area  involved  are  almost  always 
involved  in  lupus.  Erysipelas  frequently  develops  in  the  lupus  ulcers 
(habitual  erysipelas  of  lupus  patients).  This  acute  inflammation  of  the 
skin  has  a  healing  effect  upon  the  lupus,  for  the  infiltration  may  degen- 
erate and  disappear  by  absorption  after  such  an  infection. 

A  carcinoma  may  develop  upon  a  lupus.  The  beginning  of  a  carci- 
noma is  indicated  by  the  darker  color  and  induration  of  the  area  in- 
volved. 

Treatment. — Complete  excision  of  the  area  involved,  together  with 
the  subjacent  fat,  is  the  safest  treatment,  provided  the  lupus  is  cir- 
cumscribed. It  should  be  remembered  tliat  fre(iuently  single  tubercles 
are  foiuid  in  the  most  superficial  layers  of  the  subcutaneous  tissues. 
The  resulting  defect  should  be  covc^red  by  skin-grafting.  It  is  best 
to  use  in  grafting  large  cutis  grafts,  for  the  epidermal  strips  shrink 


Fig.  161. — Papillary  Tuberculosis  of  the  Skix. 


408  WOUND    INFECTIONS   OF    DIFFERENT   ORIGINS 

when  used  upon  the  face  and  hand,  and,  besides,  keloids  frequently 
develop  after  removal  of  these  tuberculous  lesions. 

Excision  is  impossible  when  the  lesion  is  extensive — for  example,  if 
it  involves  all  the  skin  of  the  face.  The  diseased  tissue  should  then 
be  removed  with  the  sharp  spoon  as  recommended  by  Volkmann.  After 
the  hemorrhage  is  controlled,  separate  remaining  islands  of  granulation 
tissue  should  be  destroyed  with  the  Paquelin  cautery.  If  Ilollaender's 
hot-air  apparatus  is  employed  without  previous  curettage,  a  beautiful 
sear  develops  after  the  eschar  is  detached,  but  soon  new  nodules  de- 
velop, as  the  hot  air  has  but  a  suixn'ficial  action. 

Plastic  operations  (rhino-,  cheilo-,  and  blepharo-plasty)  should  not 
be  attempted  until  the  lupus  has  completely  healed. 

Koch's  tuberculin  is  no  longer  used  in  these  cases,  as  it  is  danger- 
ous. It  produces  a  severe  reaction  in  the  diseased  area,  resembling 
erysipelas  clinically.  Transitory  healing  follows  its  use,  as  the  tuber- 
culous tissue  is  rapidly  destroyed.  After  the  patient  becomes  immu- 
nized against  the  tuberculin  there  is  no  longer  any  local  reaction,  and 
new  tubercles  develop  in  the  scar. 

The  X-ray  and  Finsen's  light  therapy  appear  to  give  the  best  re- 
sults and  should  be  regarded  as  the  treatment  of  choice  in  most  cases. 

(b)  TUBERCULOSIS   OF   SUBCUTANEOUS  TISSUES 

(Scrofulodcrmiu — Tuberculous  Gumma) 

This  form  of  tuberculosis  develops  most  frequently  in  children  as 
circumscribed  nodules  in  the  subcutaneous  tissues  covering  tuberculous 
foci  in  lymph  nodes  and  bones.  Occasionally  it  develops  in  adults 
along  the  course  of  the  lymphatic  vessels  of  the  extremities  which  drain 
a  lupus.  The  slvin  covering  the  nodule  becomes  bluish  red  in  color, 
and  after  the  contents  of  the  nodule  soften  and  the  debris  ruptures 
through  the  skin,  large  chronic  ulcers,  in  the  floor  of  which  tuberculous 
granulation  tissue  may  be  seen,  develop. 

Excision,  curettage  with  the  sharp  spoon,  tami)oning  with  iodoform 
gauze,  and  removal  of  the  primary  focus  are  indicated  in  the  treatment. 

(c)  TUBERCULOSIS   OF   MUSCLE 

Tuberculosis  of  muscle  is,  as  a  rule,  secondary  to  a  deep  ulcer  of 
the  skin  or  mucous  membrane  (e.  g.,  on  the  cheek,  lips,  or  tongue),  or 
follows  1h(>  rupture  of  a  tuberculous  focus  situated  in  a  bone,  joint, 
or  lyiiipli  node.  I'sunlly  tlic  ])i'()('(\ss  is  a  clu'onic  inflammation  of  the 
interstitial  substance  of  the  nnisele,  associated  with  the  formation  of 
tuberch^s  and  subsefjuent  destruction  of  the  contractile  substance.  Ab- 
scesses develop  when  the  larger  masses  of  granulation  tissue  become 


TUBERCULOSIS 


409 


Fig.   162. — Tuberculou.s    Ulcer    over    a    Dls- 
EASED  Rib. 


easeated  and  li(|uefied.     When  these  are  incised  or  rnpture  spontane- 
ously, large  amounts  of  cicatrieial  tissue  develop  in  the  muscle. 

As  compared  to  these  secondary  forms,  the  so-called  primary  hasma- 
togenous  tuberculous  myositis 
(myositis  tuberculosa)  is  rare. 
This  form  of  tuberculosis  may 
produce  large,  fungous,  and 
caseous  foci  or  abscesses  in  the 
muscle  which  should  be  incised 
and  thoroughly  curetted  and 
tamponed  with  iodoform  gauze 
(Lorenz). 

(d)  TUBERCULOSIS  OF  THE 
MUCOUS  MEMBRANES 

Tuberculosis  of  the  mu- 
cous membranes  of  the  ga.stro- 
intestinal  tract  and  upper  res- 
piratory passages  is  most 
frequently  secondary  to  a  tu- 
berculosis of  the  lungs,  the 
infection  being  carried  in  the 

swallowed  or  expectorated  sputum.     xV  ha^matogenous  infection  of  nui- 
cous  membranes  is  possible,  but  rarely  occui's. 

Tuberculosis  of  the  Mucous  Membrane  of  the  Mouth,  Lips,  and 
Tongue. — The  relatively  rare  pi-imary  infections  of  th(>  nnieous  mem- 
brane of  the  mouth,  lips,  tongue,  and  nose  may  develop  after  slight 
injuries,  if  large  enough  numbers  of  bacilli  are  introduced  in  the  food 
or  air,  as  they  easily  become  attached  to  areas  deprived  of  their  epi- 
thelium. Injuries  of  the  mucous  membrane  of  the  mouth  by  pointed, 
carious  teeth,  of  the  mucous  membrane  of  the  nasal  cavity  by  the 
finger  nail,  by  which  bacilli  may  be  introduced  at  the  same  time,  are 
important  factors  in  this  form  of  infection.  If  infection  occurs,  small 
miliary  nodules  or  nodular  infiltrations  develop,  from  which  extremely 
painful  ulcers  may  result  which  may  be  supei'ficial  or  deep.  These 
ulcers  have  a  granular,  often  yellowish,  floor,  and  und(>rmined,  corroded 
edges  which  are  not  indurated  as  in  carcinoma.  It  is  not  difficult  to 
make  a  diagnosis  in  these  cases,  as  small  nodules  and  ulcers  are  present 
in  the  surrounding  tissues. 

Pharyngeal  Tuberculosis. — A  di.sseminated  tuberculosis  of  the  mucous 
membrane  of  the  pharynx  frequently  occurs  in  advanced  cases  of  tuber- 
culosis of  the  lungs.  In  lupus  of  the  face  a  disseminated  tuberculosis 
of  the  lips  and  gums  is  rarely  absent,  occurring  either  as  a  primary  or 


410  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

secondary  infection.  The  nuicoiis  membrane  is  reddened  and  granular 
and  bleeds  easily  when  touched,  if  regressive  changes  have  occurred 
and  the  nodules  have  been  transformed  into  irregular,  painful  ulcers. 

Tuberculosis  of  the  Tonsils. — The  palatal  and  pharyngeal  tonsils,  be- 
cause of  their  structure  and  the  friction  to  which  they  are  exposed  in 
the  first  act  of  swallowing,  are  especially  apt  to  become  infected  with 
bacilli  which  are  contained  in  the  sputum  and  particles  expectorated 
by  tuberculous  patients.  Primary  infection  by  inhalation,  by  the  in- 
gestion of  infected  food,  and  by  saliva  with  which  a  tuberculous  mother 
moistens  an  artificial  nipple  has  been  observed.  This  form  of  infection 
is  especially  frequent  in  children,  in  whom  the  tonsils  may  be  the  source 
of  an  extensive  glandular  tuberculosis  of  the  neck.  Tuberculosis  of 
the  tonsils  cannot  be  diagnosed  unless  ulcers  are  present.  Usually  it 
can  be  made  microscopically  only  by  the  demonstration  of  tuberculous 
changes  in  the  extirpated  hypertrophied  tonsils.  Tuberculosis  of  the 
Eustachian  tube  and  middle  ear  may  follow  a  tuberculosis  of  the  mu- 
cous membrane  of  the  nasopharynx. 

Laryngeal  Tuberculosis. — The  larynx  is  likewise  frequently  involved 
secondary  to  tuberculosis  of  the  lungs;  the  rare  primary  infection  may 
follow  the  inhalation  of  tubercle  bacilli  when  the  nuicous  membrane  is 
irritated  or  chronically  inflamed.  The  nodules  and  ulcers  which  de- 
velop upon  the  vocal  cords  are  frequently  mistaken  for  carcinoma. 

Intestinal  Tuberculosis. — The  mucous  membrane  is  most  frequently 
involved  in  intestinal  tuberculosis,  especially  at  those  points  where  there 
are  lymphatic  follicles.  The  sputum  swallowed  by  tuberculous  patients 
is  the  most  important  etiological  factor.  It  contains  large  masses  of 
bacilli  which  are  not  destroyed  in  the  stomach,  and  the  mucous  mem- 
brane of  the  intestines  is  thus  constantly  exposed  to  infection.  About 
ninety  per  cent  of  all  cases  of  tuberculosis  of  the  respiratory  passages 
are  accompanied  by  the  intestinal  foi'm  of  the  disease.  Primary  intes- 
tinal tubercuh)sis  has  been  demonstrated  in  but  a  few  cases  (Cornet). 
Tubei'culous  intestinal  ulcers  are  usually  multiple.  They  extend  along 
the  course  of  the  lymphatics  and  are  circular  as  a  rule.  These  ulcers 
may  cause  a  perforation  of  the  intestinal  wall,  or  if  they  heal,  a  cica- 
tricial stenosis.  Ueo-ca'cal  tuberculosis  is  frequently  of  the  hyperplastic 
type,  and  large  masses  are  formed  which  may  be  mistaken  for  carci- 
noma. Ulcers  and  fistula'  not  infrequently  develop  when  the  rectum 
is  involved. 

Treatment. — Tuberculosis  of  mucous  membranes  is  rarely  limited  to 
a  small  area,  and  radical  ti-eatment,  excision  of  the  accessible  lesions, 
can  be  employed  in  exceptional  cases  only.  Cauterization  with  fifty  to 
eighty  \)or  cent  lactic  acid  or  an  eight  per  cent  solution  of  zinc  chlorid 
are  the  best  known  methods.     Nodules  and  deep  ulcers  may  be  curetted 


TUBERCULOSIS  411 

with  a  sharp  spoon  or  cauterized  with  the  actual  cautery.  Fistulas 
in  ano  should  be  treated  by  the  methods  advised  in  operative  surgeries. 
Resection  or  anastomosis  may  be  indicated  in  the  treatment  of  stenosis 
following  tuberculosis  of  the  intestine.  The  intestine  should  be  re- 
sected, if  possible,  in  hyperplastic  tuberculosis.  If  resection  is  contra- 
indicated,  a  lateral  anastomosis  between  the  ileum  and  .ascending  colon 
may  be  made  to  exclude  the  diseased  bowel. 

(e)    TUBERCULOSIS  OF   LYMPHATIC   VESSELS  AND  NODES 

Lymphatic  nodes  adjacent  to  tuberculous  foci  are  almost  always 
diseased.  Orth,  Wesener,  and  Cornet  have  shown  that  tubercle  bacilli 
may  pass  through  mucous  membranes  without  producing  any  patho- 
logical changes,  and  the  last  has  also  demonstrated  that  they  may 
even  pass  through  the  uninjured  skin.  Not  infre([uently  lymphatic 
nodes  become  infected  when  there  are  no  pathological  changes  found 
in  the  mucous  membranes  which  they  drain  (e.  g.,  tuberculosis  of 
mesenteric  and  cervical  lymph  nodes  in  children).  The  findings  of 
the  authors  above  mentioned  explain  how  this  can  occur.  The  nearest 
node  retains  the  bacilli,  which  multiply  and  then  pass  to  adjacent 
nodes.  The  gradual  extension  of  the  infection  from  node  to  node  may 
be  followed  especially  well  in  animals   (Cornet). 

Tuberculosis  of  Lymphatic  Vessels. — Tuberculosis  of  the  lymphatic 
vessels  is  rare,  if  those  cases  are  excluded  in  which  the  thoracic  duct 
(in  miliary  tuberculosis)  or  the  chylous  vessels,  which  may  be  ti'aced 
through  the  mesentery  to  the  receptaculum  cliyli,  are  involved  second- 
ary to  tuberculosis  of  the  intestines.  In  rare  cases  a  tuberculous 
lymphangitis  develops  in  the  extremities,  most  frequently  in  the  upper 
(Jordan).  The  symptoms  are  pronounced  only  when  the  superficial 
lymphatics  are  involved,  especially  when  there  are  tuberculous  ulcers 
upon  the  hand  or  foot,  or  ulcers  and  fistula?,  which  have  followed  the 
rupture  of  an  osteal  focus.  In  this  form  of  tuberculosis  one  or  a  num- 
ber of  small  nodules  from  which  ulcers  or  larger  subcutaneous  nodules 
may  develop  form  along  the  lymphatic  vessels.  The  nodules  may 
soften  and  discharge  externally.  Large,  cordlike  infiltrations,  which 
later  caseate,  have  been  observed  along  the  course  of  the  lymphatic 
vessels,  and  when  softening  occurs,  abscesses,  fistula?,  and  deep  ulcers 
develop.  A  provisional  diagnosis  of  tuberculosis  of  the  deep  lymphatic 
vessels  may  be  made,  if  an  abscess  which  has  no  connection  with  bone 
or  a  joint  develops  in  the  course  of  the  larger  lymphatic  vessels. 

Tuberculosis  of  Lymph  Nodes. — Tuberculosis  of  lymph  nodes  (lymph- 
adenitis tuberculosa)  may  develop  at  any  age,  but  is  most  frequent 
between  the  fifteenth  and  twenty-fifth  years  (Fischer). 

The  lymphatic  nodes  become  enlarged  when  infection  occurs.     This 


412 


WOUND   INFECTIONS   OF   DIFFERENT  ORIGINS 


enlargement  is  due  partly  to  the  increase  in  the  number  of  cellular 
elements;  chiefly,  however,  to  the  development  of  tubercles.  These  de- 
velop throughout  the  whole  node  and  fuse  so  that  sometimes  large  case- 
ous foci  rapidly  develop  {vide  Fig.  164)   and  soften,  so  that  abscesses, 

which  may  include  all  the 
glandular  tissue,  form.  A  case- 
ous, purulent  periadenitis  de- 
velops as  the  process  extends, 
and  the  nodes  then  become 
firmly  adherent  to  surrounding 
structures  (other  nodes,  mus- 
cles, large  vessels,  etc.).  The 
caseous  masses  may  rupture 
through  the  skin  if  a 
tuberculous  abscess  does 
not  develop.  An  acute 
general  miliary  tuber- 
culosis follows  the  rup- 
ture of  a  caseated  cervi- 
cal lymph  node  into  the 
internal  jugular  vein, 
or  the  rupture  of  a  case- 
ated bronchial  lymph 
node  into  the  pulmonary 
vein.  If  the  caseous  ma- 
terial becomes  inspissated  and  calcified,  small  round  calcium  concretions 
may  be  found  (especially  in  the  bronchial  and  mesenteric  lymph  nodes). 
The  less  the  caseation,  the  greater  the  hyperplasia  with  the  develop- 
ment of  large  epithelioid  cells  is  and  the  longer  the  disease  remains  con- 
fined to  single  nodes,  which  may  attain  a  large  size.  In  the  hyper- 
plastic form  of  tuberculosis  the  nodes  become  firm  and  solid,  and  but 
little  or  not  at  all  adherent  to  surrounding  structures  (non-caseating, 
indurated  form,  large-cell  h^'perplasia  of  lymph  nodes  of  Ziegler). 

In  rare  cases  the  nodes  may  undergo  a  pure  hyperplasia,  in  which 
no  or  but  few  tubercles  develop.  In  this  form  of  tuberculosis  a  large 
number  of  widely  separated  chains  of  lymph  nodes  may  become  dis- 
eased. Clinically,  it  resembles  closely  pseudoleukcemia  (aleuka?mic 
adenie),  and  can  only  be  differentiated  from  the  latter  by  the  demon- 
stration of  tubercle  bacilli  in  the  lymph  nodes. 

Tuberculosis  of  the  cervical  lymph  nodes  is  most  important  surgi- 
cally, 'i'liey  are  most  frecjueiilly  involved,  nliout  ninety  per  cent 
(Fischer)  oi"  the  cnses  of  tuberculosis  of  lymph  nodes  occurring  in  them. 
The  disease  most  frecpiently  begins  in   the  nodes  of  the  submaxillary 


Fig.  163.— Group  of  Tuberculous  Lymph  Nodes  Removed 
BY  Operation.  Caseous  foci  may  be  seen  upon  the  cut 
surface  of  the  nodes  and  also  showing  through  the  capsule. 


TUBERCULOSIS 


413 


triangle,  as  all  the  lymphatic  vessels  which  drain  the  face,  mouth,  and 
pharynx  unite  to  empty  into  these.  In  descending  infections  (origi- 
nating usually  in  the  mouth  and  pharynx)  the  nodes  which  lie  along 
the  great  vessels  are  involved  after  the  su])maxilhiry  and  submental 
nodes.  These  nodes  extend  along  the  internal  jugular  vein  down 
to  the  level  at  which  it  joins  with  the  subclavian.  The  disease  ex- 
tends from  the  nodes  beneath  the  sterno-cleido-mastoid  muscle  to  those 
lying  in  the  posterior  triangle  of  the  neck,  a  little  anterior  to  the  bor- 
der of  the  trapezius.  In  ascending  infections,  which  develop  from 
a  focus  in  the  apex  of  the  lung,  the  lymph  nodes  in  the  supraclavicular 
fossa  become  enlarged  first. 

When  the  primary  focus  is  about  the  external  canthus  of  the  eye, 
the  frontal  or  temporal  region,  the  nodes  superficial  to  or  within 
the  parotid  gland  become  dis- 
eased; when  in  the  cheek,  the 
nodes  lying  upon  the  bucci- 
nator muscle. 

A  group  of  nodes  is  found 
in  the  axillary  fossa  beneath 
the  pectoral  muscles,  which  ex- 
tends along  the  subclavian 
vessels  to  comnumicate  with 
the  supraclavicular  nodes.  The 
disease  may  extend  along  this 
chain  from  a  focus  below,  or 
the  reverse  may  happen,  a  tu- 
berculosis may  extend  from  the 

neck  along  this  chain  into  the  axillary  fossa.  AVhen  the  primary  focus 
is  in  the  skin  or  bones  of  the  hand^  the  epitrochlear  nodes  become  dis- 
eased first. 

The  inguinal  lymph  nodes  may  become  diseased  secondary  to  a 
focus  in  the  skin  of  the  legs,  about  the  aims,  or  upon  the  penis.  When 
the  disease  involves  the  skin  of  the  leg,  the  nodes  in  the  popliteal  fossa 
may  become  diseased  first. 

Tuberculosis  of  the  mesenteric  and  retroperitoneal  lymph  nodes 
follows  a  tuberculosis  of  the  intestines.  In  children  these  nodes  fre- 
quently become  tuberculous,  even  when  there  is  no  demonstrable  lesion 
in  the  mucous  membrane. 

Tuberculosis  of  the  bronchial  lymph  nodes  is  frequently  important 
from  an  etiological  viewpoint.  It  may  be  the  origin  of  ha^natogenous 
infections  of  bone,  joints,  kidneys,  and  of  miliary  tuberculosis. 

Diagnosis. — It  is  difficult  to  make  a  diagnosis  early,  when  only  single 
nodes  are  involved  and  there  is  no  demonstrable  primary  focus.     Tuber- 


FiG.  164. — Incised  Lymph  Nodes,  Showing 
Softened  Caseous  Foci. 


414  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

culous  nodes  are  harder  than  those  undergoing  simple  inflammatory 
hyperplasia.  Sometimes  they  are  so  hard  and  firm  that  they  resemble 
carcinomatous  lymph  nodes,  and  this  should  be  kept  in  mind  in  making 
a  differential  diagnosis. 

The  gradual  but  progressive  increase  in  the  size  of  the  nodes,  and 
the  involvement  of  an  entire  chain  are  important  in  making  a  diagnosis. 
The  diagnosis  is  not  difficult  when  the  nodes  soften,  when  periadenitis, 
abscesses,  and  fistul^e  develop.  Then  the  outlines  of  the  separate  nodes 
are  no  longer  distinct,  and  they  become  attached  to  the  surrounding 
structures  and  to  each  other.  The  development  of  tuberculous  granu- 
lation tissue  about  the  openings  of  fistulae,  and  the  finding  of  caseous 
debris  in  the  pus  make  the  diagnosis  certain. 

The  rapid  enlargement  of  the  nodes  when  abscesses  are  forming, 
and  the  adhesions  which  they  form  with  neighboring  structures  may 
remind  one  of  lymphosarcoma.  Recently  diseased,  small,  hard,  movable 
glands  adjacent  to  the  softened  mass  reveal  the  true  nature  of  the 
process. 

It  is  not  always  possible  to  differentiate  between  .tuberculosis  and 
malignant  growths  of  the  lymph  nodes  of  the  mesentery,  unless  the 
general  course  of  the  disease  reveals  the  nature  of  the  pathological 
process. 

An  examination  of  the  blood  excludes  leukaemia.  Pseudoleuksmic 
glands  are  movable  upon  one  another,  and  as  the  disease  does  not  ex- 
tend beyond  the  capsule  they  do  not  contract  adhesions  with  neigh- 
boring structures.  A  small  softened  node  in  the  cheek,  adherent  to  the 
skin,  may  be  mistaken  for  an  atheroma;  in  the  neck,  if  the  skin  cover- 
ing is  not  adherent,  for  a  dermoid  or  a  branchial  cyst.  Syphilitic 
enlargement  of  the  lymph  nodes  is  indicated  by  the  ordinary  symptoms 
of  this  disease. 

Treatment. — An  attempt  should  be  made  in  the  treatment  to  remove 
all  the  diseased  lymph  nodes  and  the  primary  focus  when  possible. 
The  general  condition  of  the  patient  should  also  be  improved.  Mov- 
able glands  may  be  enucleated  by  a  finger  or  blunt  dissection  from  the 
surrounding  structures.  Adherent  groups  of  nodes  should  be  dissected 
free  with  knife  and  scissors.  It  is  impossible  to  perform  these  opera- 
tions unless  one  has  an  accurate  knowledge  of  the  anatomy  of  the  part, 
for  important  nerves  (in  the  neck,  for  example,  the  spinal  accessory 
may  be  imbedded  in  the  nodes)  or  large  veins  (internal  jugular)  may 
be  so  adherent  that  resection  may  be  necessary.  The  large  wounds 
resulting  from  extensive  radical  opt'rations  should  be  drained,  the  drain- 
age being  inserted  at  the  lowest  angle  of  the  wound,  and  even  gradu- 
ated pressure  should  be  exerted  by  the  bandage  so  that  all  dead  spaces 
will  be  rapidly  obliterated. 


TUBERCULOSIS 


415 


The  disease  may  recur  in  glands  left  behind.  This,  however,  shoidd 
not  deter  the  surgeon  from  doing  a  radical  operation  for  a  majority  of 
these  eases  recover  v^^hen  proper  treatment  is  instituted.  The  statistics 
concerning  the  results  of  the  radical  operation  in  the  treatment  of  tuber- 
culous glands  of  the  neck  are  as  follows :  fifty-four  per  cent  of  perma- 
nent recoveries,  twenty-eight  per  cent  of  recurrences,  eighteen  per  cent 
terminate  fatally.  [The  immediate  mortality  from  even  extensive  oper- 
ations for  the  radical  removal  of  taberculous  glands  is  surprisingly  low. 
In  the  statistics  given  above  eighteen  per  cent  of  the  cases  of  the  disease 
were  not  arrested,  and  death  was  the  result  of  the  involvement  of  other 
organs,  and  not  the  direct  result  of  the  operation.] 

Contra-indications  to  the  Radical  Operation. — The  radical  operation 
is  contra-indicated  when  the  general  condition  of  the  patient  is  poor, 
when  the  glands  are  very  adherent,  and  when  a  number  of  fistulas  have 
formed.  In  these  the  operation  to  be  performed  depends  upon  condi- 
tions; fistulous  tracts  should  be 
curetted,  abscesses  incised,  and  the 
caseous  masses  and  the  abscess 
membrane  removed  M'ith  a  sharp 
spoon.  Large  groups  of  nodes 
may  be  made  to  soften  by  inject- 
ing chemicals  (Lugol's  solution, 
carbolic  acid  and  sublimate  solu- 
tion, iodoform-glycerin  emulsion, 
etc.)  into  them.  The  abscess  fol- 
lowing softening  should  be  incised 
and  curetted  with  a  sharp  spoon 
or  aspirated.  The  contents  of 
large  cold  abscesses  should  be  as- 
pirated and  iodoform-glycerin 
emulsion  should  then  be  injected 
(cf.   Psoas  abscess). 

Scrofula.- — By  scrofula  is  un- 
derstood a  disease  of  children  in 
which  there  is  a  chronic  catarrh, 
eczema,  and  inflammatory  swell- 
ing of  the  nuicous  membrane  of 
the  lips,  eyelids,  and  cheeks,  asso- 
ciated with  the  enlargement  of 
the  lymph  nodes,  especially  of 
those  of  the  neck.  This  enlarge- 
ment of  the  lymph  nodes  is  caused  by  tubercle  bacilli,  which  gain  access 
to  the  lymphatics  through  the  diseased  skin  and  nmcous  membrane. 


Fig.  165.  —  Illustrating  the  Condition 
WHICH  WAS  Formerly  Known  as  Scrof- 
ula. Enlargement  of  the  nodes  of  the  neck 
and  cheek  (lymphadenitis  tuberculosa),  in- 
flammation and  rhagades  of  the  upper  lip, 
chronic  nasal  catarrh,  conjunctivitis. 


416  WOUND   INFECTIONS   OF   DIFFERENT  ORIGINS 

Some  of  these  cases  are  not  tuberculous,  the  lymph  uodes  enlarging 
as  the  result  of  the  absorption  of  pyogenic  bacteria  or  their  toxins  from 
the  inflamed  skin  or  mucous  membrane.  Sometimes  the  nodes  become 
hyperplastic,  sometimes  they  suppurate.  This  second  form,  which  Cor- 
net has  called  the  pyogenic  to  differentiate  it  from  the  tuberculous 
form  of  scrofula,  may  become  tuberculous,  as  the  conditions  which  favor 
infection  with  tubercle  bacilli  are  present  and  the  resistance  of  the 
nodes  is  reduced. 

Cases  in  which  there  is  a  tuberculosis  of  lymph  nodes,  bones,  and 
joints  should  no  longer,  as  was  formerly  done,  be  classified  as  scrofula. 

(f)    TUBERCULOSIS   OF  BONE   (TUBERCULOUS  OSTEITIS) 

Tuberculosis  of  bone  occurs  chiefly  as  a  tuberculous  osteomyelitis, 
the  bacilli  being  carried  by  the  blood  from  some  other  focus,  such  as 
a  tuberculosis  of  the  lungs,  lymph  nodes,  etc.,  although  there  are  cases 
in  which  no  primary  focus  can  be  demonstrated  even  by  a  post-mortem 
examination  (Konig).  The  disease  may  extend  from  a  joint  and  in- 
volve the  bone  secondarily.  The  possibility  of  infection  through  the 
lymphatic  channels  which  drain  an  adjacent  diseased  area  cannot  be 
excluded. 

The  bone  involvement  occurring  in  acute  general  miliary  tuber- 
culosis is  of  no  surgical  significance. 

Embolic  Origin  of  Tuberculosis  of  Bone  and  Distribution  of  Arteries. 
— Apparently  most  of  the  tuberculous  foci  in  bone  are  caused  by  the 
lodgment  of  infected  emboli  (particles  of  caseous  matter  or  groups  of 
bacilli,  the  so-called  bacterial  emboli).  The  shape  of  the  foci,  which 
is  that  of  an  infarct,  certainly  indicates  that  this  is  so.  W.  Miiller  has 
reproduced  these  changes  experimentally  by  injecting  tuberculous  pus 
into  the  arteries  of  the  extremities.  Emboli  passing  from  the  right 
heart  into  the  lungs  produce  severe  symptoms  of  lung  infarcts.  Par- 
ticles of  emboli  may  pass  into  the  radicals  of  the  pulmonary  vein  and 
be  carried  to  the  left  heart  and  from  there  into  the  general  circulation. 
It  is  also  conceivable  that  a  focus  in  the  lungs  or  bronchial  nodes  may 
rupture  into  a  pulmonary  vein,  and  that  a  general  infection  (vide  Mil- 
iary Tuberculosis)  may  develop  in  this  way. 

The  round,  irregular  foci  and  sequestra  must  frequently  be  of  em- 
bolic origin.  A  study  of  the  distribution  of  the  blood  vessels  in  de- 
veloping long  bones  shows  that  an  embolus  passing  in  either  the 
epiphyseal,  metaphyseal,  or  nutrient  arteries  will  lodge  near  the  epiph- 
ysis, which  is  the  favorite  site  for  the  development  of  the  disease  (vide 
Figs.  166  and  1G7).  Only  the  large  emboli  lodge  in  the  diaphysis 
of  long  bones,  for  the  diameter  of  the  nutrient  artery  is  not  rapidly 
reduced  l)y  branching  and  remains  of  considerable  size  vmtil  it  reaches 


TUBERCULOSIS 


417 


the  metaphysis  (vide  Fig.  166a).  Emboli  lodge  most  frequently  in 
the  diapliysis  of  short,  hollow  bones,  as  the  nutrient  arteries  branch 
soon  after  entering  the  bone  and  their  lumina  are  rapidly  reduced  in 


,C%1 


Mr 


Fig.  166a. — Femur  of  \  Foin  Weeks' 
Old  Child.  The  periosteum  and  peri- 
chondrium have  been  dissected  away. 
The  intraosseal  vessels  have  been  in- 
jected with  a  mixture  of  mercury  and 
turpentine,  and  an  X-ray  picture  has 
been  taken,  a,  Epipliyseal  arteries  ;  b, 
metaphyseal  arteries;  c,  double  nutrient 
arteries. 


Fig.  lC)6b. — TiniA  of  the  Same  Child, 
Prepared  in  the  Same  Way  as  Fig. 
166a.  a,  Epiphyseal  arteries;  b,  meta- 
physeal arteries;  c,  nutrient  artery. 


size  (Fig.  168)  (Lexer).  The 
infarctlike,  cuneiform,  and  coni- 
cal foci  result  from  the  complete 
occlusion  (embolism)  of  the  small  end-arteries  of  the  epiphysis  and 
metaphysis  of  developing  bones.  A  rich  ana.stomosis  between  these  ves- 
sels is  found  only  when  the  cartilages  become  ossified  (Langer).  Foci 
of  other  shapes  are  produced  by  the  deposition  of  small  bacterial  masses 
or  of  infected  particles  of  tissue  in  the  finest  vessels  or  in  the  capillary 


418 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


network  of  the  intraosseal  vascular  system.     According  to  Orth  a  tuber- 
culous endarteritis  involving  one  of  the  larger  intraosseal  vessels  may- 
develop   and  bacilli   may   be  car- 
3^      -  rifd  fi'om  such  a  focus  into  the 

j1>   ^K\  capillaries. 

■  ^:^     a 


..   ^.. 


's     V 


V  ,"^a 


Fig.  1 67. — ^Humerus  of  a  New-born  Child. 
Vessels  shown  as  in  Fig.  166a.  a,  Epi- 
physeal arteries;  h,  metaphyseal  arte- 
ries; c,  nutrient  artery. 


Fig.  168. — Metatarsal  Hone  of  the 
Thumb  of  a  New-born  Child. 


Fig.  169. — Thoracic  Vertebra  of  a  Four 
Weeks'  Old  Child.  The  most  impor- 
tant arteries  pass  into  the  body  of  the 
vertebra  from  behind.  Other  typical  ve.s- 
sels  are  found  in  the  transverse  processes. 


The  frequent  involvement  of  developing  bone  by  tuberculosis  is  ox- 
plained  in  part  by  its  rich  vascular  supply.  Growing  bones  are  pro- 
vided with  large  arteries,  giving  off  many  branches,  which  are  directed 
toward  the  epiphyseal  cartilages,  where  growth  is  most  active.  In  adult 
bone  the  arteries  are  small  and  give  ofT  relatively  few  branches,  of 
which  only  thos(^  in  the  region  of  the  epii)hysis  are  at  all  prominent. 

Source  of  the  Emboli. — The  bacterial  ('tiil)oli  .causing  bone  lesions 
must   originate   in   some   primary   focus.      Tubercle   bacilli    nnilti])ly   so 


TUBERCULOSIS  419 

slowly  and  their  growth  is  so  retarded  by  the  lymph  nodes  that  one  is 
not  justified  in  supposing  that  they  may  be  absorbed  directly  from  re- 
cent wounds,  uninjured  skin  and  nuicous  membranes,  and  enter  the 
circulation.  These  emboli  pass  from  a  diseased  lymph  node  into  the 
thoracic  duct  or  from  a  focus  in  the  lung  into  the  pulmonary  and  later 
into  the  general  circulation. 

If  symptoms  of  tuberculosis  of  bone  develop  after  an  injury,  it  is 
probable  that  an  encapsulated  focus,  which  up  to  the  time  the  injury 
was  received  had  produced  no  symptoms,  has  been  ruptured.  The  dis- 
ease usually  follows  the  lodgment  of  infected  emboli,  and  the  tubercle 
bacilli  are  not  deposited  from  the  blood  stream  at  the  locus  minoris 
resistentice,  as  is  the  case  with  pyogenic  cocci.  The  results  of  the  experi- 
ments made  by  Friedrich  and  Honsell  show  that  the  deposition  of 
tubercle  bacilli  is  not  determined  by  trauma,  but  of  course  an  em- 
bolus infected  with  tubercle  bacilli  may  accidentally  lodge  in  a  bone 
at  the  seat  of  injury. 

Tuberculous  osteitis  is  preeminently  a  disease  of  the  young,  although 
it  may  develop  at  any  age.  Multiple  foci,  even  in  the  same  bone,  are 
freciuent  (W.  IMiiller).  The  disease  develops  most  fre(iuently  in  the 
spongy  portion  of  long,  hollow  bones  (epiphysis  and  metaphysis,  or, 
speaking  generally,  in  the  articular  ends)  and  in  the  diajjhysis  of  short 
bones. 

Pathological  Anatomy. — At  the  point  where  the  tubei-cle  bacilli  are 
deposited,  a  focus  of  granulation  tissue  with  miliary  tubercles  may  be 
demonstrated.  In  the  beginning  the  focus  is  grayish  red  in  color  and 
translucent,  but  becomes  yellowish  in  color  as  caseation  occurs.  AVher- 
ever  such  a  focus  develops,  caries  results,  as  the  infiltrated  bony  tissue 
disappears  by  lacunar  absorption.  As  a  result  of  the  caries,  round  or 
tubular  cavities  (deep  defects  if  the  surface  of  the  bone  is  involved) 
form,  which  contain  caseous  material,  resulting  from  a  degeneration 
of  the  granulation  tissue,  and  small  particles  of  bone  (bone  sand).  As 
a  rule  a  tuberculous  abscess  in  bone  is  circumscribed,  rarely  becoming 
larger  than  a  hazel  nut,  and  is  separated  from  the  sui-roundiug  healthy 
bone  by  a  connective-tissue  capsule  (abscess  membrane).  Small  bones, 
like  those  of  the  carpus,  may  be  completely  destroyed  by  caries. 

Tuberculous  Sequestra. — ^Usually  a  se(iuestrum  is  formed  in  the 
tuberculous  focus  even  when  softening,  licpiefaction,  and  caseation  occur 
rapidly.  A  sequestrum  is  practically  always  formed  in  tuberculous 
foci  in  children.  The  trabeeuhe,  infiltrated  with  caseous  material,  be- 
come necrotic,  although  in  the  beginning  they  may  be  thickened  as  a 
result  of  the  inflammation.  In  children,  the  center  of  ossification  in 
the  epiphysis  may  become  necrotic.  Slowly  the  necrotic  bone  (seques- 
trum)   is  separated  from  the  surrounding  parts  by  a  demarcating  in- 


420 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


'\ 


y 


fiammation  and  the  digestive  action  of  the  grannhition  tissue.  The 
tuberculous  sequestrum  is  smooth  or  somewhat  uneven,  round  or  oblong, 
yellowish  white  in  color,  and  harder  than  the  surrounding  bone,  which 
is  softened  by  granulation  tissue.  The  form  and  size  of  the  sequestrum 
correspond  approximately  to  the  form  and  size  of  the  original  focus. 
It  may  be  as  large  as  a  pigeon  egg.  A  sequestrum  which  is  not  com- 
pletely separated  remains  firmly  attached  at  some  point  or  points  with 
the  surrounding  bone.  If  both  processes,  caries  and  necrosis,  are  com- 
bined,   cavities   filled   with    caseous   and    purulent   contents,    in   which 

completely  separated  sequestra  lie,  are 
formed. 

The  development  of  a  small  but 
appreciable  swelling  may  be  the  only 
external  sign  of  a  tuberculous  focus 
which  has  existed  for  some  time.  The 
swelling  develops  when  the  focus 
is  situated  beneath  the  periosteum,  or 
when  a  focus  situated  within  the  bone 
reaches  the  periosteum  or  ruptures 
through  it  into  the  soft  tissues.  Peri- 
osteal bone  formation  (periostitis  os- 
sificans) accompanies  foci  situated  in 
the  cortex,  especially  those  foci  which 
are  secondary  to  a  tuberculous  arthri- 
tis. A  periostitis  accompanies  foci  situ- 
ated in  the  vertebra^  and  frequently 
large  defects  in  the  vertebrae  are 
bridged  over  by  newly  formed  bone. 
The  periosteum  produces  bone  in  tuber- 
culosis of  the  phalanges,  metacarpal 
and  metatarsal  bones  giving  rise  to  the  clinical  picture  of  spina  ventosa. 
In  rare  cases  periosteal  bone  formation  accompanies  tuberculosis  of  the 
diaphyses  of  larger  bones. 

Tuberculous  foci  in  the  epiphyses  of  long  bones  and  the  resulting 
sequestra  are  frequently  cuneiform  in  shape  (according  to  W.  Miiller 
in  twenty  per  cent  of  the  cases),  the  base  of  the  wedge  resting  upon 
the  articular  cartilage,  its  apex  approaching  more  or  less  the  epiphyseal 
cartilage.  If  the  latter  is  destroyed  the  apex  of  the  wedge  may  extend 
into  the  medullary  cavity.  The  sequestra  are  the  result  of  an  embolic 
occlusion  of  the  epiphyseal  vessels,  which  branch  toward  the  articular 
cartilage.  In  rare  cases  foci  and  sequestra  of  a  similar  shape  are  found 
in  the  skull  (Gangolph)  and  in  some  of  the  short  bones  (Konig,  Krause). 
Such  foci  are  fre^iuently  found  in  the  pelvis,  tli(»  base  of  the  wedge 


I 


Fig.  170. — Vessels  in  the  Os  Innomi 

NATTJM  OF  A  NeW-BORN  ChILD. 


TUBERCULOSIS 


421 


lying  in  the  acetabulum,  while  the  apex   is  directed  above  and   poste- 
riorly (Fig.  171). 

Diffuse  Tuberculous  Osteitis. — Those  cases  in  which  the  foci  are  not 
surrounded  by  an  abscess  membrane  or  sclerotic  bone,  but  by  softened 
bone  (malacia),  permeated  with 
miliary  tubercles,  form  the 
transitional  stages  to  the  dif- 
fuse tuberculous  osteitis.  In 
this  infiltrating  progressive  tu- 
berculosis of  bone,  described  by 
Konig,  an  entire  long  hollow 
bone,  or  the  greater  part  of  it 
(the  spongy  bone,  likewise  the 
medulla  and  cortex),  may  be 
attacked  by  a  caseating  and  sup- 
purating inflammation.  Small 
or  large  abscesses  then  develop 
in  the  medullary  cavity  (osteo- 
myelitis tuberculosa  purulenta). 
This  form  of  tuberculosis  of 
bone  is  more  frequently  second- 
ary than  primary,  being  usu- 
ally secondary  to  a  tuberculous 
arthritis. 

Caries  Carnosa. — Konig  first 
described  a  rare  form  of  tuber- 
culosis of  the  humerus,  which 
is  secondary  to  tuberculosis  of 
the  shoulder  joint.  The  newly 
formed  and  old  tissues  and  the  bone  marrow,  permeated  with  miliary 
tubercles,  are  fleshlike  and  red.  This  form  of  tnlxTculosis  has  Ix-en 
called  caries  carnosa. 

Spontaneous  Healing  of  Tuberculous  Foci. — A  tuberculous  focus 
in  bone  may  heal  spontaneously.  The  bacilli  are  then  overcome  by 
the  resistance  of  the  tissues,  and  the  focus  is  either  encapsulated  or 
replaced  by  newly  formed  connective  tissue.  As  would  be  expected, 
spontaneous  healing  occurs  most  frequently  in  small,  circumscribed 
foci  in  which  there  is  no  sequestrum  formation.  Virulent  bacilli  may 
remain  in  the  encapsulated  or  healed  foci,  from  which  recurrences 
develop  when  the  capsule  is  destroyed  or  the  resistance  of  the  tissues 
lowered  by  trauma.  The  spontaneous  healing  of  tuberculosis  of  the 
spine  demonstrates  that  even  the  larger  sequestra  may  become  encap- 
sulated. 

28 


Fig.  171. — Tuberculoits  Caries  of  the  Rim  of 
THE  Acetabulum.  1.  Perforation  inward  into 
the  pelvis.  2.  Epiphyseal  cartihige.  3.  Base 
of  the  cuneiform  sequestrum  corresponding  to 
the  lower  branch  of  the  nutrient  artery.  4. 
Displacement  of  the  acetabular  rim  upward. 
Preparation  from  a  child  twelve  years  of  age. 


422 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


Fuptiire  of  a  Focus  into  a  Joint  or  Soft  Tissues. — An  osteal  focas 
may  rupture  into  a  neighboring  joint  or  into  the  soft  tissues.  If  the 
focus  ruptures  into  a  joint  a  tuberculous  arthritis  develops,  the  clinical 

^  3 


Fig.  172a. — Tuberculosis  of  the  Right 
Shoulder  Joint.  Photographed  from  in 
front.  1.  Very  large,  completely  sepa- 
rated sequestrum.  2.  Head  of  humerus 
deprived  of  cartilage  and  carious.  3. 
Tuberculum  majus.     5.   Diaphysis. 


Fig.  172b. — Resected  Head  of  the  Hu- 
merus. Natural  size  (after  Krause). 
Preparation  made  by  sawing  head  of  the 
humerus  in  frontal  plane.  1 .  Cuneiform 
sequestrum  which  extends  to  the  articu- 
lar surface,  the  cartilage  of  which  has 
been  destroyed.  2.  Extensive  caseous 
infiltration  of  the  head,  secondary  infec- 
tion extending  from  the  sequestrum  into 
the  tuberculum  majus  (4)  and  the  di- 
aphysis (5). 


Fig.  173. — Tuherculosls  of  the  Diaphysis  of  the  Tibia  of  an  I^huit  Year  Old  Girl. 
The  foci  have  been  exposed  by  chiseling  away  a  thick  layer  of  bone.  Slight  expansion 
of  the  bone.     Sclerotic  bone  surrounds  the  foci. 


course  of  which  depends  upon  the  character  of  the  primary  focus 
(Konig).  If  there  is  a  tendency  to  the  formation  of  scar  tissue  and 
healing,  the  tuberculous  process  extends  but  little  in  the  soft  tissues. 


TUBERCULOSIS 


423 


If,  on  the  other  hand,  there  is  a  tendency  to  caseation  and  suppuration, 
tuberculous  or  cold  abscesses  form.  These  abscesses  (gravitation  ab- 
scesses) follow  the  force  of  gravity,  but  may  burrow  against  it.  Large 
and  very  extensive  cold  abscesses  may  develop  from  exceedingly  small 
foci.  When  the  foci  lie  directly 
beneath  the  skin,  chronic  fistuliB 
and  ulcers  form  after  the  rupture 
of  the  abscess. 

Clinical  Course. — The  clinical 
picture  of  tuberculosis  in  dif- 
ferent bones  varies.  The  articular 
ends  of  long  hollow  bones  are 
most  frequently  involved.  Round 
or  cuneiform  foci  (foci  of  granu- 
lation tissue  and  pus  with  or 
without  sequestra)  form  which 
may  rupture  into  the  joint  or  into 


Fig.  174. — Tuberculous  Osteitis  of 
THE  First  .\xd  Second  Phalanges 
OF  the  Index  Finger  with  Ab- 
scess F0RM.A.T10N.  Subcutaneous 
abscesses  are  also  present  upon  the 
dorsum  of  the  hand. 

the  para-articular  soft  tissues; 
foci  in  the  cortex,  beneath  the 
periosteum,  or  within  the  me- 
dulla of  the  diaphysis  are 
much  less  frequent.  DilTuse 
tuberculosis  of  the  epiphysis 
and  diaphysis  of  large  bones 
is  rare  and  most  frequently 
follows  a  severe  form  of  tuber- 
culosis arthritis.  In  the  shoi-t, 
hollow  bones,  the  changes  are  most  pronounced  in  the  diaphysis.  The 
cortical  layer  of  bone  is  destroyed  from  within,  and  as  the  process 
reaches  the  surface  the  periosteum  is  stimulated  to  the  production  of 


Fig.  175. — Tuberculous  Osteitis  of  the  Proxi- 
mal Phalanx  of  the  Index  Finger.  Flask- 
like expansion  of  the  finger  caused  by  some  ex- 
pansion of  the  bone  and  the  development  of 
masses  of  granulation  tissue. 


424 


WOUND   INFECTIONS  OF   DIFFERENT  ORIGINS 


new  bone,  replacing  partially  the  cortical  bone,  whicli  is  being  de- 
stroyed. The  entire  diaphysis  may  be  filled  with  caseous  material  or 
may  contain  one  large  sequestrum.  The  old  name  spma  ventosa  is 
frequently  applied  to  tuberculosis  of  the  phalanges,  metacarpal,  and 
metatarsal  bones.  Tuberculous  osteitis  of  the  phalanges  gives  to  the 
fingers  a  peculiar,  bottle-shaped  form,  which  may  also  be  produced  by 
a  tuberculous  periostitis. 

Tuberculosis  of  the  vertebra?  is  very  common;   they   are  the  most 
frequently  attacked  of  all  the  short  bones.     Frequently  multiple  foci 

develop  upon  the  an- 
terior surface  of  the 
body  of  a  vertebra  be- 
neath the  anterior 
longitudinal  ligament 
or  within  the  bone. 
These  foci  soften,  and 
the  diseased  bone  is 
then  crushed  by  the 
weight  of  the  super- 
imposed vertebra*.  The 
spine  of  the  diseased 
vertebra  becomes 
prominent,  and  an  an- 
gular kyphosis  or  gib- 
bus  develops.  If  a 
number  of  vertebrae 
are  diseased,  the  ky- 
phosis will  be  rounded 
instead  of  angular. 
Spontaneous  healing 
of  inaccessible  foci  oc- 
curs frequently.  The 
well-known  deformity 
"  humpback  "  is  the 
result  of  a  healing  of 
a  tuberculous  spond.V- 
litis  in  malposition. 
As  the  tuberculosis  heals  there  is  a  periosteal  formation  of  bone  upon 
the  anterior  surface  of  the  vert(>l)ne.  (Jrnvitation  abscesses  frequently 
develoj)  ill  llic  course  ol"  liiliereiiloiis  spondylitis.  The  retropharyngeal 
aiifl  psoas  abscesses  are  the  best-known  examples.  Tubei-culosis  of  the 
lamina*  is  much  rarer  than  that  of  the  bodies  of  the  vertebrie  (being 
most  frequent  in  the  atlas  and  axis). 


Fig.  176. — Tuberculous  Caiiies  of  the  Twelfth  Thor- 
acic, First  and  Second  I^umbar  Vertkbr.k;  Marked 
FoRMATifJN  OF  Osteophytes  upon  the  Anterior  Sur- 
face OF  THE  Sacrum.     Left  half  of  tlie  pelvis  removed. 


TUBERCULOSIS  425 

Tuberculosis  of  the  carpal  and  tarsal  1)()iies  is  frequently  followed 
by  severe  tuberculous  arthritis. 

The  ribs  are  most  fre([uently  involved  of  any  of  the  flat  bones.  Su- 
perficial, subperiosteal  foci,  which  may  become  very  extensive,  and 
larger  osteal  foci  with  sequestra  develop.  The  frontal  and  parietal  are 
the  skull  bones  most  frequently  attacked.  The  foci  of  gi-anulation  tis- 
sue and  sequestra  nuiy  perforate  the  bone  and  extend  to  the  dura ;  the 
dura  will  be  exposed  when  an  abscess  of  the  scalp  is  incised,  and  the 
granulation  tissue  and  sequestra  removed.  Tuberculosis  develops  fre- 
quently in  the  outer  part  of  the  orbital  process  of  the  superior  maxilla 
and  in  the  malar  bone,  where  it  articulates  with  the  latter.  It  may 
also  develop  in  the  scapula,  clavicle,  sternum,  and  ilium. 

Symptoms. — Clinically,  as  a  rule,  the  first  symptoms  of  tuberculosis 
of  bone  consist  of  pain  and  swelling.  These  develop  as  soon  as  the 
focus  within  the  bone  reaches  the  periosteum  and  soft  tissue.  Suppiu'a- 
tion  in  the  soft  tissues  and  rupture  into  a  joint  give  rise  to  definite 
symptoms  (see  below).  The  tuberculous  abscess  in  the  soft  tissues 
develops  slowly  and  the  skin  covering  it  does  not  present  any  of  the 
signs  of  inflannnation  (cold  abscess).  There  is  but  a  slight  elevation 
of  tenq^erature  in  uncomplicated  tuberculosis  of  bone ;  frequently  there 
is  no  fever  at  all.  High  fever  indicates  a  secondary  infection  with  pyo- 
genic bacteria,  which  frequently  occurs  when  a  suppurating  fistula  com- 
municates with  the  abscess  cavity,  or  it  indicates  the  beginning  of  a 
miliary  tuberculosis. 

Diagnosis. — U.sually  the  diagnosis  of  tuberculosis  of  bone  is  not  dif- 
ficult. Tuberculosis  of  the  vertebra^  skull  and  facial  bones,  ])lialanges, 
and  a  number  of  other  bones  presents  a  very  definite  clinical  picture. 
The  slow  development  of  the  abscess  following  the  inflammation  of 
bone,  the  absence  of  local  as  well  as  general  synqitoms  of  acute  inflam- 
mation, the  distention  of  the  skin,  the  rupture  of  the  abscess  with  sub- 
sequent development  of  chronic  fistula^  and  uleei-s  with  flabby,  yellow 
granulations  and  undermined  edges,  and  finally  the  swelling  of  adjacent 
lymph  nodes  leave  no  doubt  as  to  the  nature  of  the  pathological  process. 
Besides,  tuberculosis  develops  most  freciuently  in  the  bones  of  weak 
individuals,  in  whom  there  are  already  evidences  of  some  other  form 
of  tuberculosis,  such  as  tuberculosis  of  the  lungs,  lymph  nodes,  joints, 
skin,  or  mucous  membrane. 

Sometimes  it  is  difficult  to  make  a  difiPerential  diagnosis  between 
tuberculous  and  suppurative  osteomyelitis,  especially  when  the  foci  pro- 
duced by  the  latter  are  small,  are  situated  in  the  articular  ends  of  the 
bone,  and  pursue  a  subacute  or  chronic  eour.se.  Expansion  of  the  bone 
speaks  against  tuberculosis.  Only  in  the  rare  cases  of  pi-imary  tuber- 
culosis of  the  shaft  of  long  bones  does  the  cortical  layer  of  bone  become 


426  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

expanded  to  resemble  clinically  spina  ventosa,  already  described  in 
tuberculosis  of  short,  hollow  bones.  If  there  are  no  characteristic  ab- 
scesses, fistuliP,  or  ulcers,  it  may  be  impossible  to  make  an  accurate 
differential  diagnosis  before  operation.  The  caseous  pus  and  the  round, 
small  sequestra  of  tuberculosis  are  very  different  from  the  thick,  creamy 
pus,  and  the  irregular,  notched  seqviestra  resulting  from  pyogenic  in- 
fection. In  doubtfid  cases  the  demonstration  of  cocci  in  the  pus,  or  of 
tubercle  bacilli  in  the  granulation  tissue  determines  the  diagnosis.  The 
diagnosis  of  tuberculosis  may  sometimes  be  made  with  the  X-ray  if 
cuneiform  sequestra  are  present. 

Treatment. — The  most  important  indication  in  the  treatment  of 
tuberculosis  of  bone  is  to  remove  accessible  foci,  especially  if  they  sup- 
purate. This  can  be  done  when  the  epiphyseal  focus  has  ruptured 
externally,  when  the  inflammation  involves  the  bones  of  the  skull  and 
face,  ribs,  etc.  Large  epiphyseal  foci  should  be  operated  upon  as  soon 
as  possible  in  order  to  protect  the  joint  from  the  disease.  The  operation 
should  also  be  performed  as  early  as  possible  in  tuberculosis  of  the 
short,  hollow  bones.  If  the  disease  is  allowed  to  progress,  the  form 
of  the  fingers  and  toes  is  destroyed  and  changes  occur  which  interfere 
with  their  function.  The  early  operation  should  be  performed  wdien- 
ever  the  focus  can  be  demonstrated  and  is  accessible. 

All  operations  upon  the  extremities  should  be  performed  under 
Esmarch's  artificial  ischa^mia.  Frequently  removal  of  the  focus  with  a 
sharp  spoon,  after  an  incision  has  been  made  down  to  the  bone  and  the 
periosteum  has  been  reflected  to  either  side,  is  sufficient.  In  other  cases 
it  will  be  necessary  to  use  a  chisel  to  remove  a  sequestrum  which  is 
not  completely  separated,  or  to  expose  and  remove  the  contents  of  the 
medullary  cavity,  as  in  the  treatment  of  suppurating  osteomyelitis.  If 
the  latter  is  necessary,  the  epii)hyseal  cartilages  should  always  be  spared 
when  possible  (Fig.  173).  The  resulting  cavities  should  be  tamponed 
with  iodoform  gauze  or  filled  with  iodoform-glycerin  emulsion  after  the 
skin  sutures  have  been  inserted.  Resection  of  the  diseased  parts  of  flat 
bones  (ribs,  scapula,  and  ilium)  gives  the  best  results.  Resection  of  the 
joint  is  indicated  if  the  focus  in  the  bone  has  ruptured  into  the  joint 
and  produced  severe  destructive  lesions;  amputation  is  occasionally  in- 
dicated in  tlie  infiltrating,  progressive  form  of  tu])erculous  osteitis.  The 
treatment  depends  upon  the  ])(n\v  involved  (e.  g.,  vertebra). 

[In  the  treatment  of  all  forms  of  tuberculosis  gi-eat  strc^ss  should  be 
laid  ui)on  the  necessity  of  improving  the  general  condition  and  raising 
the  resistance  of  the  patient.  Out-of-door  life,  good  food,  plenty  of  sun- 
shine, and  rest  are  as  essential  as  surgical  treatment.] 

The  treatment  of  tulx^rculous  abscesses  developing  from  osteal  foci 
differs,  depending  uj)()n  the  position  of  the  latter. 


TUBERCULOSIS  427 

In  small  abscesses  with  a  subjacent,  osteal  focus,  the  following  treat- 
ment is  to  be  recommended :  incision,  removal  of  the  abscess  membrane, 
and  insertion  of  a  tampon  of  iodoform  gauze.  If  the  abscess  is  very 
large,  a  tampon  should  not  be  inserted,  but  the  incision  should  be  su- 
tured and  iodoform-glycerin  emulsion  then  injected  between  the  stitches 
into  the  cavity  (Billroth).  This  treatment  cannot  be  employed  when 
the  abscess  has  opened  spontaneously  or  is  acutely  intl;imed,  for  in  those 
cases  the  dangers  associated  with  a  phlegmon  recpiire  free  incision  and 
open  treatment. 

It  is  difficult  to  cure  abscesses  by  incision  when  there  is  an  inacces- 
sible osteal  focus.  A  psoas  abscess  is  a  good  example  of  a  lesion  of 
this  character.  In  these  cases  the  osteal  focus  keeps  up  a  continuous 
secretion,  and  after  evacuation  of  the  contents  of  the  abscess  a  fistula 
forms  which  it  is  often  difficult  to  protect  from  secondary  pyogenic  in- 
fections. These  secondary  infections  aggravate  both  the  local  and  gen- 
eral condition,  and  therefore  incision  of  gravitation  abscesses  should 
be  attempted  only  after  the  treatment  by  aspiration  has  been  tried  with- 
out success. 

Large  syringes  and  canula^  should  be  used  in  aspirating  cold  ab- 
scesses, for  the  pus  contains  numerous  fragments  of  tissue  and  flakes 
of  fibrin.  If  these  occlude  the  canula  an  attempt  should  be  made  to 
remove  them  with  a  wire  or  fine  probe.  The  canula  should  be  inserted 
obliquely  through  the  skin  and  soft  tissues,  so  that  the  edges  of  the 
wound  will  agglutinate  rapidly  when  the  canula  is  removed.  The  for- 
mation of  a  fistula  may  be  prevented  in  this  way.  For  the  same  reason 
it  is  recommended  that  a  small  incision  be  made  before  the  insertion 
of  very  large  canulte  (Henle). 

Iodoform-glycerin  emulsion  should  be  injected  after  the  removal  of 
the  pus  (von  JMosetig-Moorhof,  Billroth,  von  IMikulicz).  The  results 
following  the  use  of  this  emulsion  are  better  than  those  following  the 
use  of  iodoform-ether,  carbolic  acid,  and  zinc  chlorid  solutions,  and  it 
is  generally  employed.  A  ten  per  cent  emulsion  of  iodoform  in  glycerin 
is  employed.  The  emulsion  should  be  thoroughly  shaken  before  btnng 
used,  and  should  be  made  fresh  frecpiently  (at  least  once  a  week). 
According  to  the  experience  of  von  Bergmann's  clinic,  it  is  not  neces- 
sary to  sterilize  this  emulsion.  The  activity  of  the  emulsion  seems  to 
be  reduced  by  sterilization,  and  besides  iodin,  which  is  harmful,  is  set 
free  in  the  process. 

This  enuilsion  may  be  injected  into  a  large  abscess  cavity  through 
the  canula  used  for  aspirating  the  jins.  Fifty  c.c.  (in  small  children 
10  c.c.)  may  be  injected  into  such  a  cavity.  If  the  abscess  membrane 
has  been  removed  and  there  are  raw  surfaces,  only  from  10  to  20  c.c. 
(in  children  a  corresponding  smaller  amount)  should  be  injected,  unless 


428  WOUND    INFECTIONS   OF    DIFFERr]NT   OllIGlNS 

free  escape  is  provided  between  the  stitch-holes,  because  of  the  dangers 
of  poisoning  following  absorption. 

The  injections  should  be  repeated  after  intervals  of  from  two  to 
four  weeks.  Frequently  abscesses  heal  under  this  treatment.  The 
emulsion  also  has  a  favorable  action  upon  the  osteal  focus.  Careful 
asepsis  should  be  practiced  while  the  injections  are  being  made  in  order 
to  prevent  secondary  infection.  If  the  latter  occurs  the  abscess  should 
be  incised  immediately  and  treated  by  the  open  method.  Fistula?  fol- 
lowing the  rupture  of  gravitation  abscesses  frequently  heal  when  iodo- 
form-glycerin  emulsion  is  injected  and  the  granulation  tissue  lining  the 
fistula  is  repeatedly  curetted  away. 

The  value  of  the  emulsion  depends  upon  the  irritation  produced  by 
the  iodoform  which  remains  in  contact  with  the  tissues  for  some  time. 
As  a  result  of  this  irritation  a  healthy  granulation  tissue,  which  tends 
to  contract  and  in  which  new  tubercles  cannot  develop,  forms,  while  the 
old  tuberculous  granulation  tissue  is  destroyed.  Iodoform,  which  is 
decomposed  in  the  tissues,  undoubtedly  has  some  influence  upon  the 
bacteria,  but  this  is  little. 

A  word  of  warning  should  be  spoken  against  the  use  of  excessive 
amounts  of  the  ennilsion.  Severe,  even  fatal,  iodoform  intoxication  has 
been  observed  after  the  injection  of  the  emulsion  into  abscess  cavities 
and  joints.  Many  patients  are  very  susceptible  to  iodoform,  and  the 
use  of  even  small  amounts  of  the  ennilsion  may  be  followed  by  a  gen- 
eral reaction  associated  with  high  fever  and  the  symptoms  of  intoxi- 
cation. Naturally  the  emulsion  should  not  be  used  when  the  patient 
gives  a  history  of  susceptibility  to  iodoform.  Sometimes  after  the  in- 
jection there  are  an  increased  pulse  rate  and  an  elevation  of  tempera- 
ture associated  with  an  acute,  transitory  nephritis  with  ha^moglobinuria, 
which  has  been  regarded  as  due  to  the  glycerin  (Henle). 

(g)    TUBERCULOSIS  OF  JOINTS   (TUBERCULOUS  ARTHRITIS) 

Tuberculosis  of  joints  follows  hannatogenous  infections,  the  rupture 
of  a  primary  osteal  focus  into  a  joint;  more  rarely,  a  tuberculosis  of 
adjacent  tendon-sh(>aths.  It  is  possible  for  infection  to  be  carried 
through  lymphatic  vessels  from  diseased  lyiiq)h;itic  nodes  situated  near 
a  joint.  Tuberculous  arthritis  is  rarely  a  primary  infection,  as  there 
is  a  focus  in  some  oth(>r  part — for  example,  in  the  lung,  bronchial  or 
mesenteric  lymph  nodes,  mucous  membrane  or  skin  (Konig).  Trauma 
has  tlu!  same  relation  as  an  etiological  factor  to  tuberculous  arthritis 
that  it  has  to  tutx'i-culous  osteitis. 

In  the  majoi'ity  of  cases  of  tubei-culous  artlu'itis  the  disease  begins 
in  the  articular  end  of  one  of  the  bones  entering  into  the  formation  of 
the  joint,   and   the  synovial   membrane   becomes   involved  secondarily. 


TUBERCULOSIS  429 

Primary  synovial  tuberculosis  is,  however,  more  frequent  than  was 
formerly  considered  to  be  the  case.  [^Nlliller's  statistics,  published  from 
Konig's  clinic,  show  that  in  232  cases  of  tuberculous  ai'thritis,  the  dis- 
ease began  in  bone  in  158,  in  the  synovial  membrane  in  46,  and  that 
in  28  cases  the  origin  could  not  be  determined.]  According  to  Konig 
a  number  of  the  osteal  foci  must  be  regarded  as  secondary  to  a  synovial 
tuberculosis. 

The  disease  develops  most  frequently  in  the  first  two  decades  of  life. 
The  knee,  hip,  and  elbow  joints  are  most  fre([uently  iiivolved,  and  in 
the  order  of  frequency  as  given.  The  joints  may  be  involved  in  acute 
general  miliary  tuberculosis. 

Pathological  Anatomy  of  Different  Forms. — The  formation  of  tuber- 
culous granulation  tissue,  in  which  are  imbedded  numerous  miliary 
tubercles,  a  chronic  reactive  inflammation  of  the  synovial  mcmbi'ane, 
and  the  production  of  an  exudate  follow  the  depo.sition  and  mu]tii)li- 
cation  of  the  tubercle  bacilli  in  the  synovial  membrane  of  the  joint.  Tt 
makes  no  difference  whether  the  bacilli  are  carried  into  tlie  s\'novial 
membrane  by  the  blood  or  whether  they  pass  into  the  membrane  after 
a  prinmry  osteal  focus  has  ruptured  into  the  cavity  of  the  joint.  The 
clinical  course  of  the  disease  is  determined  by  the  character  of  the 
granulation  tissue  and  the  exudate,  and  by  the  secondary  changes  in  the 
cartilages  and  bone. 

The  tuberculous  granulation  tissue,  which  appears  first  upon  the 
synovial  membrane  and  later  extends  to  the  articular  cartilages  at  the 
line  of  attachment  of  the  membrane,  may  tend  to  cicatrize  (the  fibrous, 
dry,  granulating  form)  or  to  degenerate  and  disintegrate  (soft,  slough- 
ing form).  In  the  first  form  the  synovial  membrane,  in  the  inner  layers 
of  which  are  found  many  tubercles,  is  considerably  thickened  and  its  free 
surface  is  partially  or  completely  covered  with  pale,  grayish  red  tuber- 
culous granulation  tissue  which  only  occasionally  caseates  or  suppurates. 
In  the  beginning  of  the  disease  there  is  generally  a  serous  or  a  sero- 
fibrinous exudate. 

In  the  caseating  form  of  tuberculous  arthritis  the  synovial  mem- 
brane is  covered  with  and  partly  transformed  into  soft,  spongy  granu- 
lation tissue,  while  the  para-articular  tissues  are  (edematous.  Cir- 
cumscribed caseous  foci  and  abscesses  fretpiently  form  within  this 
granulation  tissue,  which  may  rupture  into  the  cavity  of  the  joint,  and 
a  tuberculous  suppuration,  such  as  frequently  follows  the  rupture  of 
primary  osteal  foci  into  the  joint,  develops  in  tbis  way.  If  the  process 
gradually  extends  through  the  synovial  nicinbiane.  foci  of  gi-annla- 
tion  tissues  and  abscesses  develop  in  the  para-synovial  tissues,  wbieh 
may  later  rupture  through  the  skin  and  lead  to  the  formation  of 
fistulge. 


430 


WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 


Suppurative  Tuherculous  Synovitis. — Another  and  rare  form  of 
suppurative  tuberculous  arthritis,  which  has  been  observed  especially  in 
children  (in  the  knee  and  hip  joint),  develops  rapidly  after  the  miliary 
tubercles  form.  The  synovial  membrane,  which  is  but  little  thickened, 
contains  considerable  numbers  of  miliary  tubercles,  and  its  surface  is 
covered  with  an  abscess  membrane  which  can  be  easily  removed  (Syno- 
vitis suppurativa  tuberculosa,  Konig). 

Nodular  Form  of  Tuherculous  Arthritis  and  Villous  Arthritis. — 
Often  circumscribed   masses   of  granulation   tissue,    accompanied   by    a 

serofibrinous  exudate, 

(til.  A.        AS*'"'"'''  ' 


develop  within  the 
joints.  The  masses, 
which  may  become  as 
large  as  a  pigeon  egg, 
are  grayish  red  in 
color  and  are  at- 
tached to  the  fibrous 
layer  of  the  synovial 
membrane  by  a  pedi- 
cle (nodular  form  of 
tuberculous  arthritis, 
tuberculous  fibroma, 
Konig) .  These  masses 
show  no  particular 
tendency  to  caseate 
and  contain  liut  few 
tubercle  bacilli.  In 
other  cases  villous- 
like  growths,  which 
branch  like  a  tree, 
develop  in  the  syno- 
vial membrane  and 
thick,  fibrinous  masses 
are  deposited  upon  the 
membrane  or  in  the  joint  as  the  result  of  the  chi'onic  inflammation 
(villous  tubei'culous  ai'thritis)    (Fig.  177). 

An  attempt  has  been  made  to  explain  the  development  of  the  rare 
lipoma  arborescens  (Joliannes  Mliller),  which  is  most  frecjuently  asso- 
ciated with  synovial  tu))ercuh)sis  of  the  knee  joint,  as  due  to  the  growth 
of  the  synovial  villi  resulting  from  the  chronic  inflammation.  Similar 
growths  are  found  in  other  diseases  of  the  joints,  such  as  chronic  rheuma- 
tism, arthi'itis  deformans,  and  syphilis.  Of  course  iuberculosis  may  de- 
velop ill  a  joint  wliicli  already  contains  a  lipoma  arborescens  (Krause). 


Fig.  177. — Pkoi>ifi;kation  ok  the  Synovial  Villi  in  Tuber- 
culosis OF  THE  Knee  Joint.      (After  Konig.) 


TUBERCULOSIS 


431 


The  contents  of  the  joint  in  the  beginning  of  the  disease  or  in  mild 
forms  of  the  disease  are  serous  in  character  (hydrops  articuhiris  tuber- 
culosus  serosus,  Konig),  the  tinid  being  yellowish  and  clear  or  some- 
what clouded.  White  flakes  in  the  exudate  indicate  the  presence  of 
fibrin  (hydrops  fibrinosus,  Kiinig).  Fibrinous  masses,  which  may  form 
a  soft,  white  membrane,  may  be  found  in  the  joint  cavity,  most  fre- 
quently in  the  recesses  of  the  joint  and  along  the  line  of  reflection  of 
the  capsule.  Frequently  these  fibrinous  masses  lead  to  the  formation 
of  vi-llouslike  structures  and  free-bodies. 

Nice  Bodies. — The  so-called  rice  bodies,  corpora  oryzoidea,  which 
may  fill  the  greater  part  of  the 
diseased  joint,  are  round  and 
compressed,  resembling  seed- 
corn  in  shape.  They  are  soft 
and  white  and  are  covered  with 
an  exceedingly  slippery  exudate. 
Often  similar  structures  are  at- 
tached to  the  synovial  mem- 
brane by  a  pedicle;  frequently 
they  are  free  in  the  joint,  but 
a  connective-ti.ssue  center  indi- 
cates that  the  pedicle  has  been 
destroyed  and  that  the  bodies 
which  are  free  in  the  joint 
were  formerly  attached.  These 
bodies  should  always  be  re- 
garded as  the  product  of  tuber- 
culous inflammation,  for  they, 
like  the  exudate,  contain  tu- 
bercle bacilli ;  it  may  be  only 
a  few,  but  when  injected  into 
animals  they  produce  tubercu- 
losis. 

Origin  of  Bice  Bodies. — Ac- 
cording to  Konig,  Landow,  and 
Riese  the  pedunculated  and 
free  rice  bodies  develop  from 
deposits  of  fibrin ;  according  to 
Schuchardt,  Garre,  and  (! old- 
man   they   are   to   be   regarded 


Fig.  17S. — Tuuehciilosis  of  thk  Knee  Joint 
(Resectiox  Phei'akatiox).  Tho  articular 
cartilaf^es  covering  the  corresponding;  surfaci-s 
of  the  external  condyles  of  the  femur  and 
tibia  are  destroyed.  Small  depressions  may 
be  seen  in  the  articular  cartilage  covering  the 
external  conilyle  which  is  still  retained.  The 
edges  of  the  cartilage  are  infiltrated  with  tu- 
berculous granulation  tissue.  Between  the 
cartilage  anil  the  defect  fungous  masses  may 
be  seen. 


as    the    degeneration    products 

of   diseased   synovial   membrane    (fibrinoid    necrosis).      The   separation 

of  the  fibrinous  or  degenerated  layers  of  the  synovial  membrane  and 


432 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


the  form  of  the  free-bodies  are  pr<)l)al)ly  due  to  the  inovenients  of  the 
joint. 

A  purulent  tuberculous  exudate  is  rare,  and  is  found  only  in  the 
severe  forms  of  joint  tuberculosis. 

The  destruction  which  the  joint  undergoes  is  not  limited  to  the  liga- 
ments and  articular  fibro-cartilages,  which  are  infiltrated  with  tuber- 
culous granulation  tissues,  but  also  extends  to  the  articular  cartilages 
and  the  subjacent  bone. 

The  articular  cartilage  is  never  the  seat  of  primary  tuberculosis, 
although  it  may  be  attacked  and  destroyed  when  primary  osteal  or 
articular  foci  extend  to  it.  Tuberculous  granulation  tissue  extends 
from  the  synovial  membrane  to  the  articular  cartilage  and  produces 
in  it  small  holes,  funnel-shaped  depressions,  and  large  defects  which 
may  extend  down  to  the  bone.  According  to  Konig,  these  changes  are 
due  in  the  first  place  to  the  action  of  the  organized  fibrinous  masses. 

The  same  thing  is  observed  in  hasmo- 
philiac  joints.  The  destruction  of 
the  articular  cartilage  may  follow 
the  development  of  an  osteal  focus, 
the  base  of  a  sequestrum  projecting 
into  the  joint  and  being  worn  off  by 
the  movement  of  the  latter. 

Another  specific  process  observed 
in  primary  tuberculous  synovitis  is 
the  transformation  of  the  yellow 
marrow  of  the  spongy  tissue  of  the 
epiphysis  into  simple  granulation  tis- 
sue without  tubercles  (osteitis  granu- 
losa. Fig.  179).  As  the  result  of 
the  extension  of  the  inflammation  the 
bony  trabecula3  undergo  lacunar  re- 
sorption and  are  destroyed  by  osteo- 
clasts and  the  bone  becomes  soft  and 
porous.  ]\Tasses  of  granulation  tissue 
extend  into  and  tlirough  the  articu- 
lar cartilage  and  project  a.s  fungous 
growlhs  into  the  joint  cavity.  The 
ai'ticuhir  cartilage  is  perforated  like 
a  sieve  (von  Volkmann).  In  other 
cases  tlie  granulation  tissue  separates 
the  articulai-  cartilage  from  the  bone. 
II-  caclilagc  then  ;i|)p('ars  as  a  huiiii)  upon  the  bone;  in  the 


Fic;.  179. — CoKONAL  Section  of  the 
IjOweu  VjNo  of  a  Femur,  which  was 
Amputated  because  of  Extensive 
TuBEncui.osis  OF  the  Knee  Joint. 
The  spongy  tissue  of  the  epiphysis  has 
been  transformed  into  simp  e  grainila- 
tion  tissue  without  tulxTcIes  (osteitis 
granulosa).  The  articular  cartihnges 
are  raised  from  the  bone  by  this  tissue. 


The  ai'liciil; 


b«a(l   of  jlic    rciimr  ;is  ;i    hood.      Later  the  thinned  cartilage  is  broken 


TUBERCULOSIS 


433 


Fig.  180. — Section  of  the  Femuh  Involved  in 
Tuberculosis  of  the  Knee  Joint.  The  articu- 
lar cartilage  is  raised  and  separated  from  the 
bone;  the  roughened,  granulating  bony  surface 
may  be  seen  below  it.      (After  Kcinig). 


down  or  becomes  stratified  (Fig.  180).  Tubercles  develop  only  when 
the  granulation  tissue  of  this  form  of  osteitis  extends  into  the  joint. 
The  tissue  may  then  undergo 
caseation  and  puriform  soft- 
ening; the  bone,  necrosis  and 
caries  (joint  caries). 

The  articular  cartilages 
and  bone  are  destroyed  by 
suppuration  or  by  the  pres- 
sure of  masses  of  tuberculous 
granulation  tissue. 

Caries  Sicca. — There  is  a 
special  form  of  tuberculous 
arthritis  (caries  sicca,  von 
Volkmann)  in  which  the  sec- 
ondary changes  in  the  ar- 
ticular cartilages  and  bone 
develop  without  exudation. 
In  this  form  of  arthritis  a 
thin     layer     of     tuberculous 

granulation  tissue,  which  tends  to  cicatrize,  forms  and  slowly  destroys 
the  cartilage  and  bone.  An  entire  epiphysis  may  be  destroyed  while 
the  granulation  tissue  is  transformed  into  cicatricial  masses.  This 
form  of  tuberculosis  is  seen  most  frequently  in  the  shoulder  and  hip 
joints. 

Keactive  Changes. — The  reactive  changes  occurring  in  tlie  surround- 
ing tissues  also  belong  to  the  anatomical  picture  of  joint  tuberculosis. 
Thase  changes  affect  the  connective  tissues  and  periosteum.  All  the 
soft  tissues,  the  joint  capsule,  the  ligaments,  tendon-sheaths,  likewise 
the  subcutaneous  connective  tissue,  are  transformed  by  the  chronic 
hyperplastic  inflammation  into  firm  cicatricial  masses  which,  because 
of  the  atrophy  of  the  fat  and  accompanying  a?dema,  often  ac(iuire  lar- 
daceous  and  gelatinous  characteristics. 

The  same  inflammatory  irritation,  after  persisting  for  a  long  time, 
produces  changes  in  the  bone.  Especially  in  the  supinirative  form  a 
large  number  of  osteophytes  may  develop  about  the  joint  involved  as  a 
result  of  an  ossifying  periostitis. 

Spontaneous  Healing. — Tuberculous  granulations  may  cicatrize  and 
become  transformed  into  scar  tissue  in  wliich  the  tubercles  are  de- 
stroyed or  encapsulated.  Larger  foci  of  granulation  tissue  and  caseous 
masses  may  also  be  encapsulated  by  this  tissue.  Tiu>  peri-articular  tis- 
sues may  also  contract  and  the  movement  of  the  joint  become  limited 
as  the  result  of  healing  or  apparent  healing.     This  spontaneous  healing 


434  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

is  of  great  importance  from  a  therapeutic  viewpoint,  and  treatment 
should  be  instituted  which  favors  it. 

If  the  cartilage  and  bone  are  but  partially  destroyed,  if  the  infil- 
tration of  the  bone  is  not  extensive,  and  if  there  is  no  suppuration, 
spontaneous  healing  of  the  tuberculous  process  may  occur.  Adhesions 
which  may  become  ossified  then  develop  between  the  opposing  surfaces, 
and  fibrous  or  bony  anchylosis  develoi^s.  Concerning  anomalies  in  posi- 
tion following  healing,  vide  below. 

Clinical  Course  and  Symptoms. — The  symptoms  and  the  sequelse  of 
the  various  forms  of  tuberculous  arthritis  differ,  and  the  clinical  course 
of  the  disease  has  protean  characteristics,  but  the  symptoms  of  tuber- 
culosis of  some  joints  are  pronounced  and  characteristic. 

Usually  the  onset  of  tiiberculous  arthritis  is  gradual  and  the  course 
chronic.  According  to  Eovsing,  in  small  children,  especially  in  nurs- 
lings, suppurative  tuberculous  arthritis  begins  acutely  with  high  fever. 
This  form  of  the  disease  develops  most  frequently  in  the  knee  joint. 

The  prodromata  of  tuberculous  ai'thritis  are  weakness  and  a  prone- 
ness  to  fatigue  of  the  extremity  involved.  If  there  is  an  osteal  focus 
the  patient  will  have  noticed  for  a  long  time  a  radiating  pain,  which 
finally  locates  in  the  joint  when  the  arthritis  develops.  Frequently  ex- 
ertion or  slight  trauma,  such  as  movements  of  or  bearing  weight  upon 
the  joint,  or  pressure  upon  the  head  of  the  femur  if  the  hip  is  involved, 
produces  an  exacerbation  of  the  disease  accompanied  by  some  fever  and 
severe  pain.  The  first  objective  symptoms  are  a  moderate  amount  of 
swelling  due  to  exudation  into  the  joint,  thickening  of  the  capsule, 
oedema  of  the  para-articular  tissues,  and  fixation  of  the  extremity  in 
characteristic  positions  (coxitis,  abduction  and  outward  rotation,  goni- 
tis, flexion,  etc.). 

In  the  beginning  the  diseased  joint  is  fixed  to  prevent  pain,  which 
follows  every  movement.  The  patient  attempts  to  hold  the  diseased 
joint  in  the  position  which  is  the  least  painful  (Konig).  This  is  espe- 
cially pronounced  in  the  lower  extremity,  \\hen  the  patient  continues 
to  walk  after  the  disease  has  developed.  The  position  assumed  is  that 
in  which  the  capacity  of  the  joint  is  greatest  (Bonnet's  experiments 
upon  cadavers),  and  is  partly  the  result  of  reflex  nniscular  contraction. 
In  the  bf'ginning  of  the  diseases  the  abnormal  position  may  be  easily 
corrected  under  anu'sthesia. 

Konig  distinguishes  the  following  forms  of  tuberculous  arthritis; 
tnberf'nloiis  ]iydr()i)s,  granulating  tuberculous  arthi'itis  (fungus  articuli, 
tniiioi-  ;ilbiis),  su|>|)iirativ(^  tubci-culous  ai'thritis. 

1.  Tuberculous  Hydrops. — Tliis  foi-m  of  the  disease  is  seen  mosti 
fniinK'iilly  in  adults.  It  develoj)s  in  the  knee  joint,  but  also  in  the  ankle 
and  elbow  joints.     The  symptoms  usually  develop  gradually  and  there 


TUBERCULOSIS 


435 


is  no  particular  reaction,  althougli  at  times  the  onset  is  acute.  The 
joint  becomes  fiHed  with  a  serous  exiuhite,  the  capsule  becomes  dis- 
tended, and  tiuctuation  may  be 
elicited.  As  a  rule,  there  are 
no  other  distinct  evidences  of 
tuberculosis  {vide  Fig.  181). 
The  movements  of  the  joint 
are  restricted  as  the  articular 
structures  are  distended  and 
painful.  Contractures  rarely 
develop. 

Flakes  of  fibrin  in  the  fluid 
removed  by  aspiration  often 
indicate  the  tuberculous  na- 
ture of  the  process.  A  definite 
diagnosis  can  be  made,  if 
there  are  no  other  symptoms 
of  tuberculosis,  only  by  a  mi- 
croscopical demonstration  of 
the  bacilli  or  the  positive  re- 
sults following  inoculation  of 
animals  with  the  fluid.  It  is 
often  difficult  to  differentiate 
between  this  form  of  arthritis 

and  the  arthritis  due  to  trauma,  floating  bodies,  syphilis,  chronic  gonor- 
rhea, and  that  accompanying  suppurative  osteomyelitis. 

The  exudate  may  gradually  disappear  and  spontaneous  healing  may 
occur.  Recurrences  are  frequent.  Very  often  the  serous  exudate  is 
merely  the  first  stage  in  the  development  of  a  fungous  tuberculous 
arthritis,  the  exudate  gradually  disappearing  and  fungous  masses  de- 
veloping. The  diagnosis  is  not  so  difficult  when  there  are  large  amounts 
of  fibrin  in  the  exudate  (hydrops  fibrinosus),  for  then  peculiar  grat- 
ing sensati(ms  may  be  elicited  when  the  soft  swellings  in  the  capsule, 
which  fluctuate  but  little,  are  palpated.  These  grating  sensations  are 
caused  by  the  displacement  of  fibrinous  masses,  villi  and  rice  bodies 
upon  each  other.  Similar  deposits  and  villous  growths  may  be  present 
in  other  diseases  of  joints  (haemophiliac  joints,  chronic  rheumatism, 
arthritis  deformans),  and  for  this  reason  the  tuberculous  nature  of  the 
process  may  long  be  concealed. 

2.  The  granulating  form-  of  tuherculoiis  arfJirifis  (fungus)  is  the 
most  frequent.  Joints  which  are  superficial  gradually  assume  a  char- 
acteristic shape,  when  the  granulation  tissue  develops  in  the  joint  and 
the  para-synovial  tissues  become  swollen.     Such  joints  become  spindle- 


FlG.     IM 


i;i   i;i    I    IJ  M   ^    1  I  ■!  DKol'S   OF  THE 
lllUllT    K.NKE. 


436  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

shaped,  as  their  outlines  are  destroj^ed  by  the  distention  of  the  capsule 
and  the  swelling  of  the  para-articular  tissues.  This  becomes  more  pro- 
nounced as  the  disease  progresses,  for  the  muscles  above  and  below 
the  swelling  become  atrophic  (Figs.  182-184). 

The  soft  masses  of  granulation  tissue  often  impart  to  the  palpating 
finger  the  sensation  of  pseudo-tluctuation.     Often  the  swelling  is  hard 


Fig.  182. — Tuberculosis  of  the  Left  Knee  (Granttlating  Form,  Fungus). 

;nid  resistant,  as  the  para-synovial  tissues  have  been  transformed  into 
cicatricinl  tissue  and  the  skin  adherent  to  the  indurated  tissues  is  tense, 
shining,  and  ana-mic  (tumor  albus).  If  the  gi-anulation  tissue  tends 
to  cicatrize,  complete  healing  may  occur,  but  the  joint  will  be  anchy- 
losed,  and,  if  not  properly  treated,  in  malposition.  The  contractures 
developing  when  pi-opcr  treatment  is  not  instituted  are  due  to  the  short- 
ening of  the  umscles,  which  are  no  longei-  usedj  and  to  cicatricial  eon- 
traction  of  the  capsule  and  of  the  surrounding  tissues.     If  the  granula- 


TUBERCULOSIS 


437 


lioM  tissue  caseates  and  suppurates,  abscesses  and  fistula  develop  and 
there  is  an  evening  rise  of  temperature. 

The  greater  the  destruction  of  the  joint  the  more  marked  the  con- 
tractures, as  the  articular  ends  of  the  bones,  after  having  been  destroyed, 

become  displaced.  For  example,  dislocation 
of  the  hip  follows  destruction  of  the  head 
of  the  femur  or  of  the  upper  and  posterior 
part  of  the  acetabulum  (Fig-.  171),  genu, 
valgum  and  varum  destruction  of  the  bones 


Fig.  183. — Tuberculosis  of  the  Elbow  Joint  (Granulating  Form  with 
Abscess  Formation). 


forming  the  knee  joint.  Pathological  dislocations  and  subluxations  may 
follow  the  distention  and  weakening  of  the  ligaments  by  the  granula- 
tion tissue  and  exudate  as  well  as  the  destruction  of  the  bones.  Volk- 
mann  has  called  the  former  distention-,  the 
latter  destruction-dislocations.  They  may  de- 
velop gradually  or  after  some  insignificant 
injury. 

Diagnosis. — A  beginning  fungous  tubercu- 
losis of  a  joint  may  be  most  easily  confused 
with  an  osteal  sarcoma   (periosteal  as  well  as 
myeloid)  which  develops  into  a  joint.     Some- 
times  it   is   necessary   to   watch   the   case   for 
some  time  before  a  diagnosis  can 
be    made;    often,    Roentgen-ray 
pictures  and  exploratory  incision 
are  necessary.      Arthritis   occur- 
ring  in   hismophilia    and    associ- 
ated with  periosteal  gumma   re- 
sembles   clinically    this    fungous 
form  of  tuberculous  arthritis. 

3.  Suppurative      tuherculous 
arthritis  (cold  abscess  of  joints) 
is  much  rarer  than  the  preceding 
29 


Fig.  184. — Tuberculosis  of  the  Ankle  Joint 
(Granulating  Form  with  Fistul^e). 


438 


WOUND   INFECTIONS  OF   DIFFERENT  ORIGINS 


form.  It  is  usually  secondary  to  a  primary  synovial  tuberculosis, 
pursues  a  chronic  course,  and  is  accompanied  by  an  exudate  into  tlie 
joint.     Severe  pain  and  fever  are  absent,  and,  as  a  rule,  a  diagnosis 


Fig.  185. — Healed  Tuberculosis  of  the  Knee  Joint.     Bony  anchylosis  with  backward 

displacement  of  the  tibia. 


of  hydrops  is  made,  especially  if  the  knee  joint  is  involved.  Con- 
tractures frequentl.y  do  not  develop.  If  the  disease  is  accompanied  by 
fever,  and  if  abscesses  develop  in  the  soft  tissues,  the  diagnosis  is  no 
longer  difficult. 

Prognosis. — The  prognosis  of  tuberculous  arthritis  depends  upon  the 
general  condition  of  the  patient  and  upon  whether  or  not  there  are  foci  i 
in  other  organs.  A  majority  of  these  cases  die  of  tuberculosis  of  one  i 
of  the  viscera,  of  exhaustion,  or  amyloid  degeneration.  In  other  cases 
patients  die  of  an  acute  general  miliary  tuberculosis  or  of  a  general 
infection  following  a  suppurative  or  putrefactive  inflammation  which 
extends  along  fistulge  to  the  diseased  joint. 

The  prognosis  is  better  in  the  cicatrizing  than  in  the  suppurating 
forms  of  tuberculous  arthritis.  In  Bruns's  statistics  77  per  cent  of  the 
non-suppurating  forms  of  tuberculous  coxitis  healed,  23  per  cent  ended 
fatally,  while  in  the  suppurating  form  only  42  per  cent  recovered  and 
52  per  cent  ended  fatally. 

There  is  also  some  difference  as  regards  prognosis  depending  upon 
the  age  of  the  patient,  it  being  considerably  more  favorable  before  than 
after  the  fifteenth  year.  Only  in  rare  cases  is  the  function  of  the  joint 
completely  restored.  This  occurs  most  frequently  in  tuberculous  hy- 
drops. Some  limitati(m  of  inotion  is  the  rule;  complete  anchylosis  is 
frequent. 

Recovery,  even  with  function,  is  fre((uently  only  apparent,  for  tuber- 
culous   tissue,    fi'om   which    recurrences    may    develo]),    remains    encap-      , 
sulated.  ' 

Treatment. — Many  forms  of  tul)erculous  arthritis  tend  to  heal  spon- 
taneouslij,  and  therefore  the  first  treatment  which  is  instituted  should 
be  conservative.  If  conservative  treatment  is  i^nsuccessful,  an  opera- 
tion  (which  is  usually  re(iuired  only  in  severe  cases  or  in  those  cases 


TUBERCULOSIS  439 

in  which  the  general  condition  of  the  patient  is  poor)  is  indicated.  In 
the  conservative  treatment  an  attempt  should  be  made  to  promote  the 
healing  of  the  tuberculons  process  with  preservation  of  the  structures 
entering  into  the  joint,  if  possible,  with  motion.  If  this  is  impossible, 
an  attempt  should  be  made  to  promote  healing  with  the  parts  in  the 
most  useful  position. 

A  correctly  applied  plaster-of-Paris  bandage  is  extremely  valuable 
in  the  treatment  of  tuberculous  arthritis.  It  places  the  joint  at  ab- 
solute rest,  protects  it  from  injury,  and  hastens  by  even  and  mild 
compression  the  absorption  of  the  exudate.  If  contractures  are  pres- 
ent they  should  gradually  be  corrected  by  extension  with  weight  and 
pulley. 

Rest  in  bed  is  absolutely  indispensable  if  the  joints  of  the  lower 
extremity  are  involved,  as  any  movement  or  pressure  injures  the  dis- 
eased joint.  It  should  be  maintained  as  long  as  the  joint  is  painful 
to  pressure  or  when  weight  is  borne  upon  it  and  there  is  an  elevation 
of  temperature.  The  plaster-of-Paris  bandages  should  be  applied  after 
the  contracture  has  been  overcome  by  extension  with  weight  and  pulley. 
This  bandage  should  be  changed  after  six  or  eight  weeks,  at  which  time 
the  skin  should  be  washed  and  a  powder  or  salve  applied  in  order  to 
prevent  eczema.  If  there  are  fistulte,  fenestra  should  be  cut  in  the  cast 
in  order  that  the  dressings  may  be  changed  frequently. 

If  the  painful  stage  has  passed  (frequentlj^  it  requires  months)  and 
the  swelling  has  subsided,  the  proper  dressing  or  apparatus  may  be 
applied  and  the  patient  allowed  to  get  up.  The  dressing  or  apparatus 
used  should  be  so  applied  that  the  joint  is  kept  at  absolute  rest,  is  in 
the  proper  position,  and  bears  no  weight.  [A  proper  ajiparatus  maj'  be 
procured  from  different  instrument  makers.  A  special  surgery  should 
be  consulted  for  the  different  apparatus  used  in  the  treatment  of  tuber- 
culosis of  the  various  joints.]  A  simi^le  i)laster-of-Paris  dressing  which 
includes  the  entire  extremity  and  pelvis  is  very  satisfactory  in  the  treat- 
ment of  lesions  of  the  lower  extremity.  The  bandage  should  fit  the 
pelvis,  especially  the  ischial  tuberosities,  well,  as  the  entire  weight  will 
be  transmitted  to  them. 

Later,  when  the  joint  is  able  to  bear  some  weight,  a  light  dressing 
made  of  plaster-of-Paris,  water-glass,  leather,  or  felt,  which  can  be 
removed  at  night,  should  be  worn  to  prevent  contractures.  These  may 
be  discarded  when  there  is  no  longer  any  tendency  to  the  development 
of  contractures. 

The  contractures  due  to  reflex  muscular  contraction  and  cicatricial 
contraction  of  the  capsule,  which  are  almost  always  present  when  the 
patients  present  themselves  for  treatment,  may  be  overcome  in  a  few 
days  by  extension  with  weight  and  pulley.     If  ambulatory  treatment 


440  WOUND    INFECTIONS   OF    DIFFERENT   ORIGINS 

is  indispensable  and  a  plaster-of-Paris  cast  must  be  applied,  the  con- 
tracture may  be  gently  corrected  under  ana:'stliesia.  If  the  contracture 
is  due  to  the  cicatricial  contraction  of  the  para-articular  tissues  and 
shortening  of  the  muscles,  gradual  extension  with  the  weight  and  pulley 
is  the  best  procedure,  as  forcible  correction  {brisement  force)  may  rup- 
ture encapsulated  foci  and  cause  a  local  exacerbation  or  a  general  mil- 
iary tuberculosis.  If  it  is  absolutely  necessary  that  ambulatory  treat- 
ment be  instituted,  the  correction  should  be  made  at  a  number  of 
different  sittings,  the  correction  obtained  at  each  sitting  being  main- 
tained by  the  application  of  a  well-fitting  plaster-of-Paris  dressing. 

Frequently  an  operation  (resection  of  the  joint,  osteotomy)  is  re- 
quired to  correct  the  deformities  resulting  from  fibrous  and  bony 
anchylosis. 

The  intra-articular  medicinal  treatment,  introduced  by  Iliiter,  Bill- 
roth, and  von  Bruns,  is  of  great  value  in  the  conservative  treatment  of 
these  cases.  Of  the  many  agents  which  have  been  tried,  ten  per  cent 
iodoform-giycerin  emulsion,  employed  first  by  von  Bruns  and  others, 
is  the  most  useful.  (For  details  concerning  iodoform-giycerin  emulsion, 
vide  p.  427). 

Injection  of  lodoforni-Glycerin  Emidsion. — After  the  removal  of 
the  exudate  10  to  20  c.c.  of  the  emulsion,  in  children  5  to  10  c.c,  should 
be  injected  into  the  large  joints.  The  joint  should  be  gently  rubbed 
or  kneaded  after  the  injection  in  order  to  distribute  the  emulsion.  In 
fungous  tuberculosis  small  amounts  should  be  injected  at  a  number  of 
different  points,  the  injections  being  repeated  after  intervals  of  from 
two  to  four  weeks,  and  the  exudate  which  has  reformed  being  removed 
if  necessary.  Between  injections  the  joint  should  be  innnobilized  in  a 
plaster-of-Paris  cast  as  described  above.  Of  course  the  asepsis  must 
be  as  nearly  perfect  as  possible  when  these  injections  are  made. 

Para-articular  abseess(>s  and  fistuhi^  should  also  be  treated  by  in- 
jections {vide  Tuberculosis  of  Bone). 

A  two  to  three  per  cent  solution  of  carbolic  acid  may  be  used  in 
patients  who  are  very  susceptible  to  iodoform. 

The  conservative  treatment  (iunnobilization),  which  is  frequently 
combined  with  injections  of  iodoform-giycerin  enudsion,  is  indicated  in 
every  recent  case  of  tubei-culous  arthritis  and  should  be  tried  for  some 
time  in  old  cases.  If  the  local  or  general  condition  does  not  improve,  if 
the  tuberculous  process  is  extending,  if  there  is  a  large  primary  osteal 
focus  or  severe  secondary  involvement  of  cartilage  and  bone,  operative 
treatment  slioiild   no  longer  ])e  delayed. 

Conservative;  ti'eatmeiit  is  not  suited  for  the  cases  in  which  there  is 
a  tuberculosis  of  some  of  the  viscera  (lung  or  kidney),  in  which  the 
general  condition  is  not  good    (old  people),  and  in  which  the  fistulaj 


TUBERCULOSIS  441 

coiiiiiiiiiiicatiiiy  with  the  joints  liave  beennie  infected  wilh  pyogenic  or 
putrefactive  bacteria. 

Usually,  conservative  treatment  must  l)e  continued  foi'  a  number  of 
years,  as  recurrences  are  frequent  and  the  process  of  repair  is  prolonged. 

According  to  Konig,  the  results  of  conservative  treatment  are  more 
favorable  in  those  cases  deve]()i)ing  before  the  fifteenth  year  than  later. 
His  statistics  concerning  the  results  of  the  conservative  treatment  of 
tuberculosis  of  the  knee  joint  are  as  follows:  Before  the  fifteenth  year, 
52  per  cent  recover;  after  it,  22  per  cent.  Ilenle  believes  that  79.3  per 
cent  of  the  cases  of  tuberculosis  of  the  large  joints  recover  before  the 
fifteenth  year;  62.5  per  cent  after  it. 

Bier  has  observed  that  patients  with  passive  congestion  of  the  lungs 
(e.  g.,  in  heart  lesions)  acquire  a  certain  immunity  against  tubercu- 
losis, and  has  advised  and  used  extensively  passive  hypera^mia  in  the 
treatment  of  tuberculosis  of  bones  and  joints.  Helfericli  had  formerly 
employed  passive  hypera^mia  in  the  treatment  of  delayed  union  follow- 
ing fractures,  and  it  had  been  employed  earlier  by  Dumreicher  in  the 
treatment  of  old  ununited  fractures.  In  producing  the  hyperaMuia 
an  elastic  constrictor  should  be  applied  above  the  diseased  joint.  It 
should  exert  just  enough  pressure  to  induce  a  warm  passive  hyper- 
a'mia.  If  the  extremity  becomes  blue  and  cold,  the  constrictor  should 
be  loosened  cr  removed  and  reapplied.  Surgeons  differ  as  to  the  value 
of  passive  hypera'mia  in  the  treatment  of  tuberculosis  of  bones  and 
joints. 

Operative  treatment  is  indicated  in  those  cases  in  which  there  is 
tuberculosis  of  some  of  the  viscera  (lung  and  kidney),  in  those  in  which 
there  is  extensive  bone  involvement,  and  in  those  cases  which  do  not 
improve  under  conservative  treatment.  The  operation  should  be  per- 
formed under  artificial  iseha^mia,  and  incisions  should  be  employed 
which  give  the  best  view  of  the  parts  involved.  All  diseased  or  appar- 
ently diseased  tissue  should  be  removed  with  knife,  scissors,  and  sharp 
spoon.  When  the  diseased  synovial  membrane  is  entirely  removed,  the 
bone  should  be  examined  and  any  foci  which  are  found  should  be  re- 
moved. Para-articular  abscesses  and  foci  of  granulation  tissue  should 
be  opened;  their  walls  should  be  excised  or  removed  Mith  a  sharp 
spoon.  In  simple  cases  this  partial  arthrectomy  is  sufficient.  If  the 
articular  cartilages  and  the  epiphyses  are  destroyed,  a  typical  resection 
must  be  performed.  In  young  subjects  the  epiphyseal  cartilage  should 
be  preserved  in  order  to  prevent  later  shortening  of  the  bone. 

The  wound  should  not  be  completely  closed;  any  recesses  should  ])e 
tamponed  or  drained.  Healing,  with  fibrous  anchylosis  with  some  move- 
ment or  complete  bony  anchylosis,  occurs  in  about  two  months.  A  light 
splint,  a  plaster-of-Paris  or  starch  dressing,  which  maj'  be  easily  re- 


442  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

moved,  should  be  worn  during  the  after-treatment  to  prevent  the  con- 
tractures which  are  apt  to  develop. 

In  some  cases  amputation  is  better  than  resection.  Amputation  is 
especially  indicated  in  old  people,  in  patients  with  tuberculosis  of  the 
viscera,  in  extensive  involvement  of  bone,  and  in  those  cases  in  which 
there  is  secondary  infection  with  pyogenic  bacteria. 

According  to  Poncet,  there  is  an  articular  rheumatism  which  is  of 
tuberculous  origin.  It  develops  in  tuberculous  subjects  and  presents 
different  clinical  pictures,  occurring  in  acute,  chronic,  and  anchylosing 
forms.  It  is  probably  due  to  the  toxins  of  tubercle  bacilli  or  to  attenu- 
ated forms  of  the  same  (Mohr).  Lexer  once  saw  an  acute  form  of  this 
arthritis  follow  an  extirpation  of  tuberculous  lymph  nodes,  a  general 
miliary  tuberculosis  developing  soon  afterwards. 

(h)  TUBERCULOSIS  OF  TENDON-SHEATHS  AND  BURS^ 

The  clinical  course  of  this  form  of  tuberculosis  is  as  protean  as  that 
of  tuberculous  arthritis.  In  spite  of  the  many  transitions  four  prin- 
cipal forms  may  be  diff'erentiated : 

1.  Serous  tuberculous  hydrops,  tuberculous  hygroma:  Synovial 
membrane  covered  with  tuberculous  granulation  tissues.  Pure  serous 
exudate. 

2.  Serofibrinous  tuberculous  hydrops,  rice-body  hygroma :  Synovial 
membrane  covered  with  tuberculous  granulation  tissue,  or  with  villous, 
fibrinoid  growths,  little  serous  exudate,  few  or  many  corpora  oryzoidea 
(cf.  Joints). 

3.  Granulating  form  with  cicatrization,  fungus :  The  connective  tis- 
sue of  the  sheath  is  transformed  into  tuberculous  granulation  tissue 
varying  from  1  to  2  cm.  in  thickness.  There  is  little  or  no  exudate; 
occasionally  nodular  masses  of  granulation  tissue  develop,  which  may 
become  as  large  as  a  pigeon's  egg. 

4.  Granulating  form  with  suppuration,  cold  abscess :  Walls  of  sheath 
covered  with  caseated  granulation  tissue.  Pus  and  granulation  tissue, 
which  may  rupture  externally,  are  present  in  the  sheath. 

All  these  different  forms  may  be  primary  or  secondary  to  some 
neighboring  focus  in  bone  or  joint.  They  may  develop  in  one  or  many 
sheaths  and  may  also  occur  symmetrically.  Tuberculous  tendo-vaginitis 
is  most  frequent  in  the  upper  extremities,  the  large  synovial  sheaths  of 
the  flexor  tendons  at  the  level  of  the  wa'ist  joint  and  of  the  extensor 
communis  digitorum  on  the  dorsum  of  the  hand  being  most  frequently 
involved.  In  the  foot  the  disease  attacks  most  frequently  the  sheaths 
of  the  extensor  and  i)eroneal  nnisclcs.  Primary  tuberculous  bursitis 
may  develop  in  any  bursa.  It  is  much  rarer  tlmn  secondary  tubercu- 
lous bursitis. 


TUBERCULOSIS 


443 


Clinical  Course. — The  clinical  course  is,  as  a  rule,  chronic.  The  first 
symptoms  are  radiating  pain,  limitation  of  motion,  weakness  of  the 
part  involved,  and  the  development  of  a  long,  flat  swell- 
ing along  the  tendon.  The  connection  with  the  tendon 
is  indicated  when  movements  are  made.  In  the  fore- 
arm and  palm  an  hour-glass  swelling  is  often  produced 
by  the  constriction  of  the  annular  ligament,  beneath 
Avhich  the  fluid  passes  readily  from  one  swelling  to 
the  other. 

Diagnosis. — The  diagnosis  of  secondary 
tuberculous  tendo-vaginitis,  when  there  are 
evidences  of  tuberculosis  of  a  neighboring 
bone  or  joint,  is  not  difficult.  It  may  be  diffi- 
cult, however,  to  make  a  diagnosis  in  the 
primary  forms.  The  rice-body  hygroma  may 
l)e  recognized  by  the  grating  of  the  fluctuat- 
ing contents  of  the  swelling,  and  the  more 
rare  suppurating  form,  if  fistulie  are  present 
or  abscesses  are  about  to  rupture,  can  scarcely 
be  confused  with  any  other  lesion.  On  the 
other  hand,  it  is  difficult  to  distinguish  the 
pure  tuberculous  hydrops  from  that  due  to 
other  lesions  (trauma,  chronic  irritation,  rheu- 
matism, gonorrhea,  syphilis).  IMistakes  may 
easily  be  made  if  there  are  no  other  evidences 
of  tuberculosis.  [Frequently  a  microscopic 
examination  of  the  contents  and  animal  in- 
oculation must  be  made  before  a  definite  diagnosis  is  possible.  ]  In 
the  granulating,  non-suppurating  form  of  tuberculous  tendo-vaginitis, 
a  pseudo-fluctuating  or  firm,  resistant  swelling  develops  along  the  course 
of  the  tendon-sheath.  The  rare  lipoma  arborescens  has  much  th(>  same 
clinical  appearance.  Firm  nodules  in  the  walls  of  the  tendon-sheaths 
may  be  mistaken  for  tumors.  It  is  often  difficult  to  differentiate  tu])er- 
culosis  of  deep-lying  burste  in  which  there  are  masses  of  granulaticn 
tissue  from  a  tumor. 

Treatment. — The  following  fundamental  principles  should  l)e  fol- 
lowed in  the  treatment  of  these  forms  of  tuberculosis.  In  the  serous 
form,  with  but  little  thickening  of  the  synovial  sheath,  the  exudate 
should  be  removed  by  aspiration  and  iodoform-glycerin  enuilsion 
should  then  be  injected;  the  other  forms  should  be  operated  upon.  A 
long  incision  should  be  made  corresponding  to  the  long  axis  of  the 
swelling,  the  synovial  sheath  incised,  and  the  fluid  contents  allowed  to 
escape.     The  parietal  and  visceral  layers  of  the  synovial  sheath,  with 


Fig.  186. — Tuherculosis  of 
the  tendon-shr;ath  of  the 
Flexor  Tendons  of  the 
Index  Finger  (Granulat- 
ing, Cicatrizing  Form). 
Granulation  tissue  rai.ses  the 
flexor  tendons  some  distance 
from  the  bone. 


444  WOUND    INFECTIONS   OF    DIFFERENT   ORIGINS 

the  suppurating  fibrous  tissue  and  the  superficial  layers  of  the  dis- 
eased tendon  should  then  be  removed.  After  the  sutures  have  been 
inserted  and  tied,  from  5  to  10  c.c.  of  iodoform-glycerin  emulsion  should 
be  injected  between  the  sutures.  Active  and  passive  motion  and  mas- 
sage should  be  begun  as  early  as  ten  days  after  the  operation  (provid- 
ing the  tendons  are  not  extensively  involved  and  fibrillated),  as  a  good 
functional  result  is  obtained  earlier  in  this  way. 

(i)    TUBERCULOSIS  OF   SEROUS   CAVITIES  AND   DIFFERENT   VISCERA 

These  forms  of  tuberculosis  will  be  but  briefly  mentioned  and  merely 
from  the  viewpoint  of  surgical  treatment.  Tuberculous  pleurisy  most 
frequently  demands  surgical  interference  because  of  the  pressure  which 
the  exudate  exerts  upon  the  lung.  The  operations  usually  performed 
are  puncture  with  aspiration,  incision  through  an  intercostal  space,  or 
resection  of  a  rib  with  drainage.  Tuberculosis  of  the  pleura  is  rarely 
primary,  being,  as  a  rule,  secondary  to  tuberculosis  of  the  lungs,  ver- 
tebra, or  ribs,  or  developing  in  the  course  of  a  general  miliary  tuber- 
culosis. 

Attempts  have  been  made  to  cure  tuberculous  peritonitis,  which,  in 
children  especially,  is  secondary  to  tuberculosis  of  the  mesenteric  and 
retroperitoneal  lymph  nodes,  of  the  intestines,  or  of  the  abdominal  vis- 
cera, or  which  results  from  infection  through  the  blood  stream  occurring 
after  operative  procedures.  The  favorable  results  following  laparotomy 
in  many  cases  is  due  to  the  passive  hypera?mia  which  is  induced,  and  to 
the  removal  of  the  exudate. 

Tuberculosis  of  the  kidney,  the  urogenital  apparatus,  the  breast,  the 
thyroid  gland,  and  large,  solitary  cavities  in  the  lung,  if  favorably  situ- 
ated, may  be  cured  by  operative  procedures. 

GENERAL  TREATMENT  IN  LOCAL  TUBERCULOSIS 

The  general  treatment,  improvement  of  nutrition,  should  never  be 
neglected  in  the  surgical  treatment  of  local  tuberculosis. 

The  general  condition  of  the  patient  improves  most  rapidly  when 
good,  nutritious,  and  easily  digestible  food  is  supplied.  The  patient 
should  seek  a  favorable  climate  as  soon  as  possible.  Those  climates  are 
most  suital)l('  which  permit  of  an  out-of-door  life  and  an  abundance 
of  good,  fresh  air.  The  patient  should  not  return  home  and  assume 
family  relations  again,  as  other  members  of  the  family  may  be  suffer- 
ing with  the  same  disease,  or  the  quarters  may  be  cramped  and  the 
hygiene  poor.  The  ehildi-en  of  poor  people  and  poor  patients  should 
go  to  sanitaria  or  state  institutions  which  are  devoted  to  the  treatment 
of  this  disease.     Mountain  and  sea  air  or  residence  in  the  South  are  to 


TUBERCULOSIS  445 

be  especially  recommended.     Sun  baths  also  have  a  favorable  influence 
upon  the  general  condition. 

There  are  no  specific  remedies  for  tuberculosis.  Tuberculin,  of 
which  so  much  was  expected  at  one  time,  has  no  therapeutic  value.  Of 
the  many  drugs  which  have  been  reconunended,  the  creosote  prepara- 
tions are  still  preferred.  [Although  tuberculin  has  of  late  years  fallen 
into  disrepute  as  a  therapeutic  agent,  attention  has  again  been  attracted 
to  it  by  the  work  of  Wright  and  his  colleagues.  IMinute  doses  of  tuber- 
culin seem  to  have  a  favorable  effect  upon  some  cases  of  tuberculosis, 
and  may  be  tried  to  advantage,  0.001  mg.  being  injected  once  a  week. 
The  work  which  has  been  done  of  late  seems  to  indicate  that  it  is  not 
necessary  to  take  the  opsonic  index  in  these  cases,  the  tuberculin  being 
injected  once  a  week  and  controlled  by  the  condition  of  the  patient.] 

ACUTE   GENERAL   MILIARY  TUBERCULOSIS 

Tubercle  bacilli  may  invade  the  blood  stream  in  large  enough  num- 
bers to  produce  an  eruption  of  miliary  tubercles  in  a  number  of  the 
viscera  and  in  the  different  tissues  of  the  body.  This  form  of  tuber- 
culosis, which  proves  fatal  in  a  short  time,  is  of  no  surgical  significance. 
The  larger  viscera,  the  bones,  joints,  and  the  serous  cavities  are  most 
frequently  involved. 

Tuberculosis  of  a  large  lymph  gland  adjacent  to  some  large  lym- 
phatic vessel,  such  as  the  thoracic  duct,  may  extend  to  the  latter.  Tuber- 
culous foci  then  develop  in  the  thoracic  duct  and  countless  numbers  of 
bacilli  are  carried  into  the  blood,  and  a  miliary  tuberculosis  of  the 
lungs  and  other  viscera  then  develops.  Ponfick  was  the  first  to  describe 
tuberculosis  of  the  thoracic  duct.  The  involvement  of  the  radicals  of 
the  pulmonary  veins  (Weigert)  and  arteries  in  the  tuberculous  process 
is  an  important  etiological  factor  in  this  form  of  the  disease.  Large 
groups  of  bacilli  are  carried  into  the  blood  when  caseation  of  the 
nodules  in  the  walls  of  these  vessels  occurs  or  thrombi  become  detached. 

Tubercles  may  develop  in  the  vessel  wall  proper  in  two  ways :  bacilli 
may  be  deposited  upon  the  intima  (endarteritis  tuberculosa,  Benda) 
and  in  the  vasa  vasorum,  or  the  tuberculous  process  may  extend  to  the 
walls  of  the  larger  vessels  from  an  adjacent  focus  (periangitis  tuber- 
culosa). The  tuberculous  process  may  extend  from  foci  in  bronchial 
and  mesenteric  lymph  nodes,  in  the  lungs,  bones,  and  joints,  even  from 
a  focus  in  the  skin  (Demme).  An  acute,  general,  miliary  tuberculosis 
may  follow  an  operative  procedure  upon  some  tuberculous  focus,  or  a 
subcutaneous  injury  of  tuberculous  tissues    (Konig,  Wittmer). 

Clinically  there  are  differentiated  the  typhoid,  pulmonic,  and  me- 
ningeal  types   of   miliary   tuberculosis,    depending   upon    whether   the 


446  WOUND    INFECTIONS   OF    DIFFERENT   ORIGINS 

intestinal  symptoms  (diarrhoea,  intestinal  hiemorrhages),  the  pulmonic 
symptoms  (dyspnaa,  cyanosis,  cough),  or  the  meningeal  symptoms 
(convulsions,  rigidity  of  the  neck,  loss  of  consciousness,  delirium)  are 
most  prominent.  Acute  genei-al  miliary  tuberculosis  is  accompanied 
by  a  continuous  fever. 

The  patient  may  survive  a  few  hours  or  many  months.     Recovery  is 
rare. 

Literature. — Baumgartcn.  Ueber  Immunisierungsversuche  gegen  Tuberkulose. 
Berlin,  klin.  Wochenschr.,  1904,  p.  1124. — v.  Bchring,  Romer  und  Ruppel.  Tuberkulose. 
Beitr.  zur  experim.  Therapie,  1902,  Part  5. — Bier.  Hyperamie  als  Heilmittel.  Leipzig, 
1906. — Blauel.  Ueber  das  Reiskorperhygrom  der  Bursa  subdeltoidea.  Beitr.  z.  klin. 
Chir.,  Bd.  22,  1898,  p.  743. — v.  Bruns.  Ueber  die  Ausgange  der  tuberkul.  Koxitis  bei 
konservat.  Behandlung.  Chir.-Kongr.  Verhandl.,  1894, 1,  p.  1. — Cornet.  Die  Tuberkulose 
]\Iiliartuberkulose,  Skrophulose.  Wien,  1899,  in  Nothnagel's  spez.  Pathol,  und  Therap., 
niit  voUstand. — Cornet  und  A.  Meyer.  Tuberkulose.  In  KoUe-Wassermann's  Handb. 
der  pathog.  Mikroorganismen,  Bd.  2,  1903,  p.  78. — v.  Dungern.  Beitr.  z.  Tuberkulose- 
frage  auf  Grund  experim.  Untersuch.  an  anthropoiden  Affen.  Miinch.  med.  Wochenschr., 
1906,  p.  4. — Friedmann.  Experim.  Beitr.  zur  Frage  kongenitaler  Tuberkelbazillen- 
iibertragung  u.  kongenitaler  Tuberkulose.  Virchow's  Archiv,  Bd.  181,  1905,  p.  150. 
— Friedrich.  Experim.  Beitrage  zur  Kenntnis  der  chir.  Tuberkulose.  Deutsche  Zeit- 
schr.  f.  Chir.,  Bd.  53,  1899,  p.  512. — Garre.  Zur  Aetiologie  der  kalten  Abszesse. 
Deutsche  med.  Wochenschr.,  1886; — Die  primare  tub.  Sehnenscheidenentziindung. 
Beitr.  z.  klin.  Chir.,  Bd.  7,  1891,  p.  293; — Ueber  die  Indikationen  zur  konservativen 
u.  operativen  Behandlung  der  Gelenktuberkulose.  Deutsche  med.  Wochenschrift, 
1905,  p.  1878. — Gcbele  und  Ehermayer.  Ueber  Behandlung  bei  Gelenktuberkulose. 
Miinch.  med.  Wochenschr.,  1906,  p.  601. — Grober.  Die  Tonsillen  als  Eintrittspforten 
f.  Krankheitserreger,  bes.  f.  d.  Tuberkelbazillen.  Klin.  Jahrb.,  Bd.  14,  1905,  Part  6. — 
Hevle.  Die  Behandlung  der  tub.  Gelenkerkrankungen  und  der  kalten  Abszesse.  Beitr. 
z.  klin.  Chir.,  Bd.  20,  1898,  p.  363.— 0«o  Hildebravd.  Tuberkulose  und  Skrophulose. 
Deutsche  Chir.,  1902. — Honscll.  Ueber  Trauma  und  Gelenktuberkulose.  Beitr.  z. 
klin.  Chir.,  Bd.  28,  1900,  p.  659. — Jacob  und  Pannwitz.  Entstehung  und  Bekampfung 
der  Lungentub.  Leipzig,  1901. — Jordan.  Ueber  Tuberkulose  der  Lymphgefasse  der 
Extremitaten.  Beitr.  z.  klin.  Chir.,  Bd.  19,  1897,  p.  2\2.—R.  Koch.  Ueber  neue 
Tuberkulinpraparate.  Deutsche  med.  Wochenschr.,  1897,  p.  209. — Konig.  Die 
Tuberkulose  der  Knochen  und  Gelenke.  Berlin,  1884; — Die  spez.  Tuberkulose 
der  Knochen  und  Gelenke:  I.  Das  Kniegelenk.  Berlin,  1896;  II.  Das  Hiiftgelenk. 
Berlin,  1902;— Die  Tuberkulose  d.  Thoraxwand.  Arch.  f.  klin.  Chir.,  Bd.  79,  1906, 
p.  1. — Krause.  Die  Tuberkulose  der  Knochen  und  Gelenke.  Deutsche  Chir.,  1899. 
— Kuttncr.  Die  Osteomyelitis  tub.  des  Schaftes  langer  Rohrenknochen.  Beitr.  z. 
klin.  Chir.,  Bd.  24,  1899,  p.  449. — Lanz  und  de  Quervain.  Ueber  hiimatogene  Muskel- 
tuberkulose.  Arch.  f.  klin.  Chir.,  Bd.  46,  1893,  p.  97. — Lexer.  Weit.  Untersuch. 
ul)er  Knochenarterien  und  ihre  Bedeutimg  f.  krankhafte  Vorgange.  Arch.  f.  klin.  Chir., 
Bd.  73,  1904,  p.  481. — Lorenz.  Die  Muskelerkrankungen.  In  Nothnagel's  spez.  Pathol, 
und  Therap.  Wien,  1898. — Masur  und  Kockel.  Wirkung  toter  Tuberkelbazillen. 
Ziegler's  Beitr.  z.  path.  Anat.,  Bd.  16,  1894,  p.  256. — Mohr.  Der  Gelenkrheumatismus 
tubork.  L'rsprungs.  Berliner  Klinik,  1905,  Part  197. — Friedrich  Midler.  Ueber  die 
Bedeutung  der  Sclbstvcrdauung  bei  einigen  krankhaften  Zustjinden.  20.  Kongress  der 
inn.  Mediz.,  1902. — Orlh.  Perlsucht  vmd  menschl.  Tuberkulose?  Berl.  klin.  Wochen- 
schr., 1903,  p.  ()57. — Orth  und  E.sser.  Was  ist  Perlsucht?  ^  Bed.  klin.  Wochenschr., 
1902,  p.  793. — Ostertag.     Koch's  Mitteilungen  iiber  die  Boziehungen  der  Menschen-  zur 


LEPROSY  447 

Haustiertuberkulose.  Zeitschr.  f.  Fleisch-  und  Milch-hygiene.  Berlin,  1901,  Part  12. 
— Roger  et  Gamier.  Passage  du  bacille  de  Koch  dans  le  lait  d'une  femme  tub.  Compt. 
rend,  de  la  Societe  de  biolog.,  1900,  p.  175. — Schmorl  und  Geipel.  Ueber  die  Tuberkulose 
der  menschl.  Plazenta.  Miinch.  med.  Wochenschr.,  1904,  p.  1676. — Sternberg.  Ex- 
perim.  Untersuchung.  iib.  die  Wirkung  toter  Tuberkelbazillen.  Centralbl.  f.  allg. 
Pathol.,  Bd.  13,  1902,  p.  753. — v.  Szekely.  Neuere  Arbeiten  iiber  die  Frage  der  Identitat 
der  menschl.  und  der  Rindertuberk.  Centralbl.  f.  Bakt.,  Bd.  34,  1903,  Ref.,  p.  161.— 
Tavel.  Beitriige  zur  Aetiologie  der  Eiterung  bei  Tuberkulose.  Festschrift  fiir  Kocher, 
Wiesbaden,  1891. — v.  Volkmann.  Lupus  und  Tuberkulose.  Berl.  klin.  Wochenschr., 
1875,  p.  413. — Wassermann.  Tuberkulose  im  friihesten  Kindesalter.  Zeitschr.  f. 
Hygiene,  Bd.  17,  1894,  p.  343. — A.  Wassermann  und  Bruck.  Exper.  Studien  iiber  die 
Wirkung  von  Tuberkelbazillenpraparaten  au  den  tuberkulos  erkrankten  Organismus. 
Deutsche  med.  Wochenschr.,  1906,  p.  449. — A.  Weber.  Die  Tuberkulose  des  Menschen 
und  der  Tiere.  In  Kolle-Wassermann's  Handb.  d.  pathog.  Mikroorg.,  1906.  Ergiin- 
zungsband  1,  p.  107. — Wittmer.  Ueber  akute  Miliartuberkulose  nach  Operation  tuber- 
kuloser  Halsdrusen.  Bcitr.  z.  klin.  Chir.,  Bd.  33,  1902,  p.  788. — Handbuch  der  prak- 
tischen  Chirurgie  von  v.  Bergmann,  v.  Bruns,  und  v.  Mikulicz.  Abschnitte  von  Henle, 
Hoffa,  Jordan,  Lexer,  Reichel. — Internation.  Chir.-Kongress  z.  Briissel,  1905.  Traite- 
ment  de  la  tuberculose  articulaire. 


CHAPTER    XI 

LEPROSY    (elephantiasis    GR.ECORUM) 

Geographical  Distribution  and  Course  of  Extension. —  [Rieketts  gives 
the  following  sketch  of  the  course  of  extension  of  leprosy:  "Leprosy 
existed  in  Egypt  in  prehistoric  times  and  extended  to  other  lands  only 
when  intercourse  was  established  betvv-eeu  the  two  countries.  It  reached 
Greece  at  about  345  b.c,  Italy  in  the  first  century  before  Christ,  and 
from  the  latter  country  extended  to  Germany,  France,  and  Spain.  Cru- 
saders returning  from  the  Orient  also  brought  back  the  disease  in  later 
times  and  eventually  all  Europe  was  infected.  Leprosy  is  known  to 
have  existed  in  Great  Britain  in  the  tenth  century,  and  from  that  coun- 
try it  was  carried  to  Ireland  and  Greenland.  From  Germany  it  ex- 
tended to  the  Scandinavian  countries,  and  from  the  latter  to  Finland 
and  Russia.  It  also  reached  Russia  from  the  south  and  east,  and  in 
the  south  it  was  at  one  time  called  the  Crimean  disease.  The  West 
Indies  and  South  America  probably  were  infected  from  Spain,  and 
through  these  channels  the  disease  was  carried  to  the  Southern  States 
of  America.  The  leprosy  of  the  AVestern  States  seems  to  have  been 
imported  by  Norwegian  immigrants  chiefly.  In  1902  the  United  States 
Leprosy  Commission  found  278  cases  in  this  country;  186  of  these  in- 
dividuals probably  contracted  the  disease  in  this  country,  120  were  born 
in  foreign  countries,  and  145  were  native  born.  The  disease  also  ex- 
tended  around   the   globe   in   the   opposite   direction,   reaching   China, 


448  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

Japan,  and  the  East  Indian  islands  from  India.    The  Sandwich  Islands 
became  infected  in  the  nineteenth  century, 

"  The  contagiousness  of  the  disease  appears  to  have  been  recognized 
at  a  very  early  period.  In  636  a.d.  leprosy  houses  were  instituted  in 
Italy  and  other  countries,  and  the  practice  of  segregating  lepers  soon 
became  general.  The  hospitals  were  called  Lazarus  houses  in  Middle 
Europe,  and  St.  George  houses  in  Scandinavian  countries.  Pepin  and 
Charles  the  Great  declared  marriage  between  lepers  illegal.  The  rapid 
disappearance  of  leprosy  in  Middle  Europe  during  the  sixteenth  cen- 
tur.y  is  ascribed  largely  to  the  segregation  of  patients."] 

Bacillus  of  Leprosy. — The  bacillus  of  leprosy  was  first  demonstrated 
by  Hansen,  later  by  A.  Neisser.  In  form,  size,  and  staining  reaction, 
both  in  dry  preparations  and  sections,  it  resembles  closely  the  tubercle 
bacillus. 

Bacilli  of  leprosy  occur  in  groups,  while  the  micro-organism  of 
tuberculosis  occurs  singly  or  in  small  clusters  and  outside  of  the 
cells.  Leprosy  bacilli  take  the  stain  more  readily  than  tubercle  bacilli, 
and  for  this  reason  may  be  stained  with  cold  solutions.  Baumgar- 
ten  recommends  the  use  of  a  dilute,  cold  solution  of  fuchsin  (five 
drops  of  a  saturated  alcoholic  solution  in  a  watch  crystal  full  of 
water).  The  preparations  are  stained  from  six  to  seven  minutes  in 
this  solution,  are  then  detained  for  fifteen  sec- 
onds in  a  ten  per  cent  solution  of  nitric  acid  in 
alcohol,  and  are  counterstained,  after  the  acid- 
alcohol  is  removed  with  water,  in  a  dilute  solution 
of  methylene  blue.  In  this  method  the  bacilli  of 
leprosy  appear  red,  while  the  tubercle  bacilli  are 
unstained. 

They  are  found  in  largest  numbers  in  the  cellu- 
lar, inflammatory  growths  following  infection,  and 
in  the  nuicous  membranes.     They  may  be  demon- 
strated  in   the   diseased   peripheral   nerves,    in   the 
^      10-7     r)  Ivmph  nodes,  and  viscera  (liver,  spleen,  lung,  and 

Fig.   187. — Bacilli  or       '       '^  '  ^  .  . 

Leprosy    in    the    tcsticle).    Bacilli  have  also  been  found  in  the  spinal 
Skix.      (After    A.     oanulia  and  cord,  upon  the  surface  of  the  skin  and 

von  Bergmann.)  /  li    i       n         mi  i        *  i 

mucous  membranes  (Babes).  Ihey  may  be  tound 
ill  the  1)1()()(1  during  life,  if  the  blood  is  examined  during  the  febrile 
period  which  fre<iuently  accompanies  the  development  of  new  nodules. 
The  attempts  which  have  been  made  to  cultivate  the  bacilli  upon  arti- 
ficial media  and  to  produci*  the  disease  by  inoculating  animals  have  not 
been  succ(^ssfnl.  Animals  are  not  susceptible  to  leprosy,  and  therefore 
it  has  been  difficult  to  identify  the  cultures  which  some  have  claimed  to 
obtain.     In  spite  of  these  facts  a  direct  or  indirect  transference  of  the 


LEPROSY 


449 


disease  from  a  diseased  to  a  healthy  subject  can  no  longer  be  doubted, 
for  the  bacilli  may  be  demonstrated  in  inflammatory  nodules  and  infil- 
trations.    The  danger  of  infection  does  not,  however,  seem  to  be  great. 


Fig.  188. — Leprosy  Bacilli  in  the  Mu- 
cous Membrane.  (After  A.  von  Berg- 
mann.) 


Fig.  189. — Leprosy  Bacilli  in  the 
Nerves.  (After  A.  von  Berg- 
mann.) 


The  disease  is  not  inherited,  but  is  transmitted  from  one  member  of  the 
fa)ni]y  to  another  through  exposure. 

Modes  of  Infection, — The  bacilli  gain  entrance  in  some  unknown 
way,  apparently  through  the  skin  or  mucous  membrane,  and  are  then 
carried  to  other  parts  through  the  lymphatic  vessels  or  blood  vessels. 
Wherever  they  are  deposited  they  produce  a  chronic  inflammation,  re- 
sulting in  the  formation  of  a  vascular  granulation  tissue.  Nodular 
inflammatory  growths  develop  about  the  hair  follicles  (Virchow),  later 
appearing  as  large,  flat,  infiltrated  areas  and  nodules.  These  inflam- 
matory changes  occurring  in  the  nerves  produce  spindle-shaped  thick- 
enings, the  connective-tissue  fibers  of  the  nerves  become  stretched,  and 
the  nerve  fibers  are  destroyed.  All  these  pathological  changes  are 
grouped  under  the  term  leproma.  The  bacilli  lie  in  large  groups  within 
and  without  the  cells,  also  in  multinuclear  giant-cells.  They  may  be 
ea.sily  demonstrated  in  blood  discharged  from  nodules  and  from  the  skin 
after  it  is  pricked.  Large  vacuolated  cells,  called  glohi  or  lepra  cells, 
filled  to  bursting  with  degenerating  bacilli  (Virchow,  Neisser,  Hansen), 
are  supposed  to  be  characteristic  of  the  disease.  These  masses  are 
regarded  by  some  as  bacillary  thrombi  in  lymphatic  and  connective- 
ti.ssue  spaces.  The  nodules  may  ulcerate;  occasionally  they  may  become 
absorbed.  Frequently  they  remain  unchanged  when  the  height  of  their 
development  is  reached. 

Period  of  Incubation. — ^Years  may  intervene  after  the  infection  has 
occurred  before  symptoms  of  the  disease  develop.  This  is  demonstrated 
by  the  fact  that  the  people  who  have  lived  in  leprous  regions  may 
develop  the  disease  some  time  after  they  have  returned  home  where 
the  disease  does  not  exist.  In  these  cases  the  .symptoms  develop  on  an 
average  from  three  to  five  years  afterwards,   although   isolated   cases 


450 


WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 


have  been   observed   in  which  the  symptoms  developed  after  a  much 
longer  period    (twenty-seven  to  thirty-two  j^ears). 

Symptoms  and  Clinical  Course. — The  most  important,  but  not  the 
most  constant,  symptoms  in  the  beginning  of  the  disease  are  the  sensa- 
tion of  intense  cold  in  the  hands  and  feet,  hypera^sthesia,  especially 
of  the  lower  extremities,  and  erythematous  spots  which  may  appear 
upon  the  surface  of  the  entire  body  and  disappear  after  a  few  days 
without  leaving  any  trace  to  soon  reappear.  According  to  A.  von 
Bergmann,  in  some  of  the  eases  flat,  slightly  raised,  infiltrated  areas, 
varying  from  a  dull  red  to  a  brownish  red  color  and  several  centimeters 

in  diameter  may  be 
demonstrated  in  the 
skin.  These  may 
be  the  only,  though 
positive,  signs  of 
both  forms  of  lep- 
rosy, and  may  last 
for  a  number  of 
years.  According  to 
Sticker,  Kolle,  and 
others,  leprosy  be- 
gins in  a  number  of 
cases  in  the  nasal 
mucous  membrane. 

The  disease  oc- 
curs in  two  forms, 
depending  upon 
whether  the  patho- 
logical changes  are 
most  marked  in  the 
skin  or  nerves.  These 
two  forms  may  be 
combined. 

Leprosy  of  the 
skin  (lepra  tube- 
I'osa )  begins  with 
the  formation  of 
small  nodes,  some  of 
which  develop  from 
the  dull  red  or 
brownish  red  spots 
above  described.  These  give  to  the  skin  an  uneven,  tuberculated  ap- 
pearance.     General  symptoms  and   fever,   caused   by  the   diffusion  of 


Fig.  190. — Lkpra  Tuberosa.      (After  A.  von  Bergmann.) 


LEPROSY  451 

bacilli  and  their  deposition  in  the  capillaries  of  the  skin,  often  accom- 
pany these  local  changes.  While  the  nodes  upon  the  face  and  the  dor- 
sum of  the  hands,  where  they  first  develop  most  frequently,  fuse  to  form 
large  hyperaemic  spots  and  infiltrated  areas  and  masses,  which  are  cov- 
ered with  pigmented  skin  or  develop  by  gradual  growth  into  round, 
soft,  red  and  bluish  nodes  or  masses  the  size  of  a  walnut  with  broad 
bases,  new  nodes  develop,  accompanied  bj^  a  febrile  reaction,  upon  other 
parts  of  the  body,  especially  upon  the  face  and  the  extensor  surfaces 
of  the  extremitias.  The  most  marked  changes  are  always  found  in  the 
skin  of  the  face.  Nodes  and  inflammatory  masses  develop  upon  the 
forehead,  the  nose,  the  cheeks,  and  the  ears,  while  the  beard,  the  eye- 
lashes, and  eyebrows  fall  out.  The  masses  w'hich  develop  in  the  skin 
are  traversed  by  the  natural  folds  of  the  latter.  When  these  changes 
are  advanced,  the  patient  has  the  facial  expression  of  an  animal,  and 
hence  the  expressions  satyriasis  and  leontiasis,  to  describe  this  condition, 
used  by  the  ancients.  The  tumorlike  nodes  may  develop  upon  the  nose, 
the  eyebrows,  and  the  lips,  so  that  often  in  addition  to  the  deformity 
above  described  the  mouth  and  the  palpebral  fissures  may  become  nar- 
rowed. Inflammatory  masses  which  have  remained  unaltered  for  a  long 
time  may,  after  a  febrile  reaction,  swell  and  soften  and  then  disap- 
pear or  ulcerate. 

Leprosy  of  the  Mucous  Membranes. — The  mucous  membranes  are 
not  spared.  At  the  same  time  that  the  eruption  occurs  in  the  skin, 
the  conjunctiva  (with  exf;ension  to  the  cornea  and  iris)  may  become 
involved,  and  nodes  and  inflammatory  masses  may  develop  in  the  mu- 
cous membrane  of  the  nose,  buccal  cavity,  and  pharynx  (especially  upon 
the  soft  palate),  and  in  the  larynx. 

Involvement  of  the  latter  produces  not  only  the  raucous  voice  of 
leprosy  (Vox  rauca  leprosa),  but  frequently  also  laryngeal  stenosis. 

Chronic  ulcers  of  the  skin  and  mucous  membranes  follow  the  break- 
ing down  of  these  nodes  and  masses.  Ulcers  of  the  leg  are  frequent 
in  leprosy,  and  the  demonstration  of  bacilli  in  their  secretion  is  proof 
positive  that  they  have  followed  the  ulceration  of  preexisting  nodes. 
The  lymph  nodes  adjacent  to  the  diseased  area  may  become  swollen 
and  reach  quite  a  considerable  size.  A  chronic  periostitis  may  give 
to  the  bones  of  the  part  involved  a  spindle-shaped  enlargement  (de  la 
Camp). 

The  clinical  course  of  the  disease  varies.  In  one  patient  isolated 
and  unaltered  nodes  may  be  the  only  indication  of  the  disease;  in  an- 
other new  inflammatory  masses  and  ulcers  develop  one  after  another; 
and  in  still  another  case  there  may  be  a  transition  to  the  nervous  form 
of  leprosy.  The  patient  becomes  a  chronic  invalid  and  death  occurs  in 
from  five  to  nine  years,  the  result  usually  of  leprosy   or  of  amyloid 


452 


WOUND   INFECTIONS  OP   DIFFERENT  ORIGINS 


degeneration  of  the  important  viscera.     It  is  frequently  due  to  exten- 
sive involvement  (partly  leprous,  partly  tuberculous)  of  the  luugs. 

In  the  iiervoiis  form  of  leprosy  (lepra  nervorum,  s.  niaculo-anaas- 
thetiea),  tlat,  brownish-red,  infiltrated  areas  develop  in  the  skin.     These 

may  develop  independ- 
ently without  symptoms 
or  from  preexisting  areas. 
The  somewhat  elevated 
and  pigmented  bord(n^  of 
such  an  area  extends  into 
the  surrounding  tissues, 
while  the  center  of  the 
area  becomes  depressed 
and  white,  and  the  hair 
falls  out.  The  skin  be- 
comes atrophic,  and  the 
first  evidence  of  distui'b- 
ance  of  nerve  function 
(ancesthesia)  is  found  in 
these  white  areas.  These 
areas  which,  formerly  de- 
pending upon  whether 
they  ^^•ere  pigmented  or 
not,  were  spoken  of  as 
white  and  black  leprosy 
(morphfpa  alba  and  ni- 
gra), may  be  very  ex- 
tensive and  often  extend 
synnnetrically  resembling 
in  outline  a  map.  Accord- 
ing to  A.  von  Bergmann, 
in  the  nervous  form  of 
the  disease  bacilli  are 
not  found  in  the  fiat,  infiltrated  areas.  According  to  Danielssen  and 
Balx's,  oidy  a  few  bacilli  are  present,  aud  it  is  difficult  to  demonstrate 
them. 

The  evidences  of  nerve  involvement  ai-e  most  frecpiently  seen  first 
along  the  course  of  the  ulnar,  median,  peroneal,  aud  facial  nerves.  The 
sciatic  and  femoral  nei-ves  may  b(>come  diseased.  Sensory  disturb- 
ances are  the  most  prominciil.  P>a('i!li  and  mild  inflammatory  changes 
have  been  found  even  in  the  sj)inal  and  (Jasserian  ganglia  and  in  the 
spinal  cord.  The  ner-ves,  when  involved,  become  thickened,  and  niay 
be   palpated    as   swollen    cords    with   spindle-shaped    thickenings.      The 


Fig.  191. — Lepra  Maculo-an.esthetica. 
(After  A.  von  Bergmann.) 


LEPROSY  453 

areas  supplied  by  the  diseased  nerves  become  anaesthetic  and  sul)jeet  to 
a  number  of  trophic  disturbances,  such  as:  (1)  Atrophy  of  groups  of 
muscles  with  motor  paralysis.  Atrophy  of  the  nuisclcs  of  the  thenar 
and  hypothenar  eminences,  of  those  upon  the  ulnar  side  of  the  forearm, 
of  the  face  and  neck,  and  in  the  interossei  spaces  occurs  earliest  and  is 
most  connnon.  (2)  Contractures  of  the  fingers  (fourth  and  fifth  most 
frequently)  and  toes;  also  of  the  forearm  and  leg.  (3)  Ulcers  due  to 
l)ressure,  which  are  round  and  develop  upon  the  sole  of  the  foot  be- 
neath the  heel  and  the  heads  of  the  metatarsal  bones.  (4)  Mutilation 
of  the  fingers  and  toes  (lepra  mutilans)  following  necrosis  of  the  pha- 
langes; mutilation  by  ulcers,  accompanied  by  a  progressive  necrosis  of 
the  connective  tissues,  so  that  separate  digits  or  the  entire  hand  and 
foot  may  slough  off  at  one  of  the  joints.  In  these  cases  small,  inde- 
pendent foci  of  leprous  granulation  tissue  develop  in  the  phalanges 
(Sawtschenko).  (5)  Vesicular  eruptions  (pemphigus  leprosus)  develop 
most  frequently  upon  the  extremities.  These  eruptions,  which  are  fol- 
lowed by  chronic  ulcers,  recur  at  irregular  intervals. 

Diagnosis. — The  diagnosis  of  leprosy  occurring  in  regions  where  it  is 
not  endemic  is  very  difficult  in  the  early  stages  of  the  disease.  Lepra 
mutilans  resembles  closely  syringo-myelia,  which  is  accompanied  by  mu- 
tilation of  the  fingers,  sensory  disturbances,  and  atrophy  of  muscles. 
Frequently  it  is  scarcely  possible  to  differentiate  between  the  two,  for 
it  is  often  difficult  to  demonstrate  the  thickening  of  the  nerves,  which 
is  the  only  definite  characteristic  of  lepra  nervorum.  In  all  doubtful 
cases  examination  of  the  nasal  secretion  for  the  bacillus  of  leprosy 
should  be  made. 

Treatment, — Patients  suffering  with  leprosy  should  be  isolated. 
They  should  receive  good  nursing  and  good  food.  Cleanliness  should 
be  exercised  in  caring  for  the  patient  and  his  surroundings.  Not  in- 
frequently surgical  interference  is  required.  The  troublesome  and 
disfiguring  tumors  developing  upon  the  face  may  be  removed.  Fingers 
and  toes,  the  seat  of  a  progressive  and  persistent  necrosis,  should  be 
amputated  or  disarticulated.  If  stenosis  of  the  larynx  develops,  it  may 
be  necessary  to  perform  a  tracheotomy.  Ulcers  developing  upon  the 
legs  and  soles  of  the  feet  should  be  dressed  aseptically  and  protected 
from  further  injury.  Danielsscn  recommends  sodium  salicylate  inter- 
nally; von  Bergmann,  Curjun  balsam  (5  drops  daily),  also  an  external 
application  of  the  same  (2.0-3.0  daily)  with  lanolin  used  as  a  salve. 

Literature. — Babes.  Die  Lepra.  Spez.  Pathologie  und  Therapie  von  Nothna- 
gel,  Bd.  24,  Wien,  1901 ; — Lejira.  In  Kolle-Wassermann's  Handbuch  der  pathog. 
Mikroorganismen.  Erganzungsband,  1906,  p.  155. — A.  v.  Bergmann.  Die  Lepra. 
Deutsche  Chir.,  1897. — dc  la  Camp.  Periostitis  bei  Lepra.  Fortschritte  auf  dem 
Gebiete  der  Rontgenstrahlen,  Bd.  4. — Hansen.     Lepra.     In  Kolle-Wasserniann's  Hand- 


454 


WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 


buch  der  pathog.  Mikroorganismen,  Bd.  2,  1903,  p.  178. — Uhlenhut  und  Westphcd. 
Hist.  u.  bakteriol.  Untersuchungen  iiber  einen  Fall  von  Lepra  tuberosa-anaesthetica. 
Centralbl.  f.  Bakteriol.,  Bd.  21,  1901,  p.  233. — Virchow.  Die  krankhaften  Geschwulste, 
Bd.  2,  p.  494. 


CHAPTER    XII 


SYPHILIS 


Spirochaeta  Pallida. — Syphilis  (lues)  belongs  to  the  chronic  infections 
diseases.  The  micro-organism  discovered  by  Schaudinn  and  E.  Hoff- 
mann in  1905,  which  is  known  as  the  spirochaeta  pallida,  is  apparently 

the  cause  of  the  disease.  The 
organism  measures  from  4  to 
14  /x  in  length,  the  average  length 
being  about  the  diameter  of  the 
erythrocyte  of  man.  Its  width 
varies  from  immeasurable  thin- 
ness to  0.5  fi.  It  possesses  from 
three  to  twelve,  sometimes  more, 
curves,  which  are  sharp  and  reg- 
ular and  resemble  the  curves  of  a 
corkscrew.  The  poles  are  sharp- 
ened. The  organism  is  motile, 
the  motions  consisting  of  rota- 
tions on  the  long  axis,  forward 
and  backward  movements,  and 
the  bending  of  the  entire  body. 
Flagella  have  not  been  seen  (Flex- 
ner).  It  stains  with  the  azur  of  Giemsa  and  with  aniline  dyes,  only 
after  being  acted  upon  for  some  time,  however. 

These  organisms  are  found  in  the  ulcerated,  more  rarely  in  the  non- 
ulcerated  chancre  and  papules,  in  the  roseola,  in  the  circulating  blood, 
and  in  the  lymph  nodes.  In  congenital  syphilis  they  are  found  in  almost 
all  the  viscera.  Their  presence  in  the  ulcers  of  late  syphilis  has  not  been 
satisfactorily  demonstrated.  The  spirochaeta  has  been  found  in  syphilis 
produced  experimentally  in  apes  (Metschnikoff  and  others).  Attempts 
at  cultivating  them  have  not  been  successfnl. 

Special  text  books  have  been  devoted  to  syphilis,  the  clinical  course 
and  symptoms  of  which  differ  very  much  in-  different  individuals. 
Every  physician  should  be  thoroughly  conversant  with  the  pathology, 


Fig.  192 


-Spiroch.eta  Pali>ida. 
white  blood  corpuscles. 


SYPHILIS 


455 


clinical  course,  complications,  and  sequelae  of  the  disease.  The  jjreater 
part  of  the  treatment  belongs  to  intei-nal  medicine. 

The  initial  lesion  (initial  sclerosis,  lluuteriau  induration,  hard  chan- 
cre) develops  at  the  point  where  the  syphilitic  virus,  which  is  discharged 
from  an  ulcerated  chancre  or  a  moist  papule  developing  in  the  early 
stag&s  of  the  disease,  gains  access  to  a  small  wound,  or  an  erosion  of 
the  skin  or  mucous  membrane.  The  virus  may  be  transferred  directly 
by  contact  of  the  syphilitic  lesion  with  the  wound  or  excoriation,  or  in- 
directly by  the  linger  or  some  object  (e.  g.,  drinking  and  eating  uten- 
sils, cigar  holder,  needle  used  for  tattooing) . 

The  extra-genital  chancre  may  develop  on  any  part  of  the  bod}^  It 
occurs  most  frequently  upon  the  face  (lip,  nose,  canthus  of  the  eye, 
tonsil,  tongue),  the  fingers,  and  breast.  The  diagnosis  is  much  more 
difficult  than  when  the  chancre  occurs  upon  the  genitalia  or  structures 
adjacent  to  them. 

After  an  incubation  period  of  from  two  to  four  weeks  a  papule  or 
an  induration,  depending  upon  whether  the  changes  are  superficial  or 
deep,  develops  about  the  infection  atrium,  which  in  the  meantime  may 
have  healed  or  have  become  transformed  into  a  deep  ulcer.  If  there 
is  a  mixed  infection,  a  soft  chancre  may  develop  within  two  days,  and 
then  the  induration,  so  characteristic  of  the  hard  chancre,  develops  in 
the  soft  chancre  after  the  usual  incubation  period. 

Appearance  of  the  Chancre. — The  initial  lesion  appears  as  a  round 
or  oval  nodule.     It  is  red,  sharply  delimited,  hard,  painless,  and  may 
become    as    large    as    a    quarter. 
Often  the  initial  lesion  is  so  small, 
especially  in  women,  that  it  may  be 
overlooked.     An  urethral  chancre  "^t 

frequently  is  overlooked,  being 
accompanied  merely  by  a  slight 
urethral  discharge,  and  the  devel- 
opment of  the  syphilitic  eruption 
may  be  the  first  indication  of  a 
preceding  infection.  If  the  epi- 
dermis covering  the  chancre  is 
cast  off,  the  ulcerated  surface  be- 
comes covered  with  a  firmly  at- 
tached crust.     When  the  crust  is 

removed  bleeding  occurs.  If  the  lesion  is  situated  upon  mucous  or  skin 
surfaces,  Avhich  are  moist,  the  surface  of  the  lesion  does  not  become 
covered  with  a  crust,  but  secretes  continuously  (moist  papule,  ulcerated 
sclerosis  of  the  genitals,  anus,  and  buccal  mucous  membrane).  The 
disintegration  of  the  infiltration,  which  is  often  hastened  by  the  use  of 


.,X#   AW" 


w. 


Fig.  193.  —  An  Ulcerated  Chancre  Ten 
Days  Old.  The  lesion,  which  followed  a 
razor  cut,  is  accompanied  by  a  marked  en- 
largement of  the  regional  lymph  nodes. 


456  WOUND   INFECTIONS   OF   DIFFERENT  ORIGINS 

caustics,  imcleanliness,  etc.,  leads  to  the  formation  of  an  ulcer.  The 
ulcer  has  a  hard,  parchnientlike  base,  and  sliyhtly  raised,  indurated, 
wall-like  borders,  which  are  not  undermined.  In  rare  cases  the  initial 
sclerosis  is  complicated  by  gangrene;  a  deep  phagedenic  ulcer  covered 
by  a  dark  crust  then  develops. 

Disappearance. — The  primary  lesion  disappears  very  slowly  after 
weeks  or  months.  The  amount  of  induration  gradually  diminishes  and 
the  cells  undergo  fatty  degeneration  and  become  absorbed. 

Ilistulogy. — Histologically  there  is  found  in  the  primary  lesion  a 
collection  of  round  and  epithelioid  cells  with  an  occasional  giant-cell. 
The  pathological  changes  occur  first  about  the  vessels;  finally  they  in- 
volve the  entire  thickness  of  the  skin  or  mucous  membrane.  The  lumina 
of  the  blood  vessels  may  become  obliterated  by  the  proliferation  of  the 
tissues  composing  them,  especially  by  a  proliferation  of  the  intima 
(endovasculitis  obliterans  syphilitica).  Frequently  these  vascular 
changes  are  the  beginning  of  regressive  changes  in  the  primary  lesion. 

Diagnosis. — The  induration  of  the  primary  lesion  is  its  most  impor- 
tant characteristic,  and  is  often  the  deciding  factor  in  making  a  diag- 
nosis. An  ulcerated  chancre  may  resemble  clinically  a  carcinoma  of 
the  skin.  In  the  chancre,  however,  the  induration  and  ulceration  de- 
velop nuich  sooner  than  in  a  carcinoma,  and  the  involvement  of  lymph 
nodes  is  nuich  more  rapid  and  extensive  in  relation  to  the  size  of  the 
lesion  than  is  the  case  in  carcinoma  of  the  skin.  Enlargement  of  lymph 
nodes  does  not  occur  with  an  ulcerated  gumma,  unless  there  is  a  second- 
ary infection.  This  enables  one  to  differentiate  between  an  ulcerated 
gumma  and  a  chancre  of  a  mucous  membrane. 

Treatment. — p]ar]y  excision  of  the  primary  lesion  is  unreliable,  al- 
though at  one  time  it  was  hoped  that  the  absorption  of  the  organism 
and  the  development  of  a  general  infection  might  be  prevented  by  this 
procedure.  Excision  is  not  employed  at  the  present  time  except  in 
rare  instances.  If  excision  is  performed  it  should  be  done  before  there 
is  any  enlargement  of  the  adjacent  lymph  nodes,  and  only  in  the  first 
week  after  th(^  development  of  the  lesion.  It  should  be  kept  in  mind 
that  the  fresh  wound  following  excision  may  become  infected  with  the 
seei-etion  of  the  chancre. 

All  that  is  necessary  in  the  treatment  of  the  chancre  is  to  keep  the 
lesion  as  clean  as  possible  and  to  avoid  irritation  and  injury.  Aristol, 
dermatol,  bisnuith  subnitrate,  or  some  other  dusting  powder  may  be 
used  and  a  gauze  dressing  a])plied.  [Caustics  should  never  be  em- 
ployed in  the  ti-ealiiieiit  of  lesions  upon  the  penis.  The  induration 
wliich  follows  the  use  of  caustics  may  render  the  diagnosis  of  doubtful 
lesions  im])ossible.  The  healing  of  a  pi'imary  lesion  is  not  favored  by 
the  use  of  any  of  these  agents.     Cleanliness  of  the  part  with  the  use 


SYPHILIS  457 

of  some  mild  ointment  or  powder  as  above  mentioned  is  indicated.  ]\Ier- 
cury  preparations  shoukl  be  avoided  in  tbe  treatment  of  any  suspected 
lesion,  as  the  appearance  of  the  initial  lesion  may  be  so  changed  and 
the  subsequent  clinical  course  of  syphilis  so  modified  that  it  may  be 
impossible  to  make  a  correct  diagnosis.]  The  general  treatment  should 
be  begun  with  the  first  symptoms  of  the  secondary  stage. 

Involvement  of  Adjacent  Lymph  Nodes. — The  lymph  nodes  adjacent 
to  the  chancre  enlarge  slowly  from  four  to  five  weeks  after  the  infec- 
tion, from  one  to  two  weeks  after  the  development  of  the  primary 
lesion,  and  become  as  large  as  a  cherry  or  nut.  They  are  painless,  hard, 
and  not  adherent  to  the  skin  or  to  neighboring  nodes,  and  form  adhe- 
sions with  adjacent  structures  only  when  secondary  infections  occur. 
Involution  of  these  lymph  nodes  is  extremely  slow,  and  they  remain 
enlarged  for  a  long  time  after  the  primary  lesion  has  completely  healed. 
Enlargement  of  nodes  adjacent  to  the  parts  upon  which  the  primary 
lesion  is  most  frequently  located  may  be  of  value  in  making  the  diag- 
nosis of  previoiLs  infection.  The  inguinal  nodes  are  the  most  frequently 
involved,  as  the  genital  is  much  more  frequent  than  the  extra-genital 
chancre.  The  enlarged  nodes  (indolent  bubo)  lie  arranged  in  a  row 
(syphilitic  rosary)  in  both  inguinal  regions  following  an  initial  lesion 
on  the  penis. 

Eruptive  Stage. — Syphilis  is  a  local  disease  until  the  lymph  nodes 
adjacent  to  the  chancre  become  enlarged;  then,  after  a  second  incu- 
bation period  of  some  weeks,  the  general  infection  of  the  body  is  indi- 
cated by  the  development  of  different  lesions  of  the  skin  and  nuicous 
membranes  (eruptive  stage).  General  symptoms,  such  as  i)ain  in  the 
head  and  extremities,  weakness,  and  mild  fever,  precede  and  accompany 
the  eruptive  stage.  At  the  same  time  all  the  palpable  lymph  nodes  be- 
come enlarged  (scleradenitis).  They  may  be  felt  as  hard  nodules  as 
large  as  a  bean  and  persist  for  years. 

In  the  eruptive  stages  a  macular,  papular,  pustular,  or  scaly  erup- 
tion develops  upon  the  skin  and  nnicous  membranes.  These  different 
eruptions,  which  may  be  combined,  are  of  great  diagnostic  significance 
and  recur  frequently   (so-called  secondary  syphilis). 

In  congenital  syphilis,  in  which,  according  to  Lesser,  the  symptoms 
of  the  different  stages  develop  in  more  rapid  succession  than  in  the 
acquired  forms,  the  different  forms  of  eruption  above  mentioned  also 
occur,  and  as  a  rule  within  the  first  two  months  of  life. 

The  late  or  tertiary  symptoms  of  the  disease,  both  in  the  acquired 
and  congenital  forms,  have  no  delinite  time  limits.  They  may  follow 
immediately  the  lesions  of  the  secondary  stage,  or  develop  while  the 
secondary  lesions  are  at  their  height  (galloping  syphilis).  Often  they 
develop  after  an  interval  of  years,  during  which  time  thci-e  may  have 
30  ' 


458  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

been  no  symptoms  of  the  disease  (latent  period).  The  tissue  changes 
characteristic  of  the  third  stage  of  syphilis  are  nnicli  more  destructive 
than  those  of  the  secondary  stage,  but  the  resulting  lesions  can  no  longer 
transmit  the  disease,  as  their  secretion  is  no  longer  infectious.  As  the 
late  lesions  are  the  ones  most  frequently  treated  surgically,  it  is  com- 
forting to  know  that  there  is  no  danger  of  specific  infection.^ 

The  Gumma. — The  gumma  (gummatous  tumor,  syphiloma,  nodular 
syphilide)  is  characteristic  of  late  or  tertiary  syphilis.  It  is  a  granu- 
lation tumor  (Virchow)  and  is  peculiar  in  that  it  may  develop  as  a 
single  or  multiple  lesion  in  any  tissue  and  in  any  part  of  the  body.  A 
gumma  develops  slowly  to  attain  the  size  of  a  walnut  or  fist,  and  the 
tissues  or  the  parenchyma  of  the  organ  in  which  the  gumma  develops 
are  infiltrated  or  replaced  by  granulation  tissue  rich  in  cells  and  blood 
vessels.  If  regressive  changes  occur  in  the  nodule,  the  tissue  which  has 
been  infiltrated  degenerates  or  is  transformed  into  a  mass  of  scar  tissue. 

Macroscopic  Appearance  of  a  Gumma.- — Upon  section,  a  recent  gum- 
ma is  of  a  grayish  or  grayish  red  color,  translucent,  and  sometimes  of 
a  gelatinous  consistency  (soft  forms,  poor  in  cells).  The  great  tend- 
ency to  undergo  regressive  changes,  peculiar  to  gummata,  is  due  for  the 
most  part  to  the  involvement  of  the  walls  of  the  blood  vessels  by  the 
syphilitic  process  (vasculitis  and  perivasculitis  syphilitica).  These  vas- 
cular changes  frequently  precede  the  degenerative  changes  in  the 
gumma.  As  the  regressive  changes  progress,  the  center  of  the  gumma 
becomes  transformed  into  a  yellowish,  opaque  focus  or  appears  to  be 
divided  into  a  number  of  necrotic  areas,  which  may  fuse,  so  that  finally 
the  necrosis  extends  and  involves  the  entire  lesion.  In  the  meantime 
the  surrounding  connective  tissue  has  proliferated  to  form  a  connective- 
tissue  capsule,  from  which  processes  extend  into  the  degenerating  mass. 

Regressive  Changes. — The  fate  of  the  gumma  differs,  depending  upon 
the  character  of  the  necrosis.  Deep  gummata  frecpiently  are  absorbed, 
disappearing  completely,  or  the  necrotic  tissue  becomes  encapsulated. 
The  nodule  may  become  transformed  by  caseation  a.nd  coagulation- 
necrosis  into  a  dry,  firm,  homogeneous  mass,  or  by  fatty  degeneration 
of  the  cells  into  a  friable  one.  If  the  necrotic  tissue  becomes  liquefied, 
abscesses  containing  a  fluid  resem])ling  pus  and  caseous  particles  foi*m. 
If  the  skin  oi-  mucous  membrane  covering  a  gumma  becomes  necrotic, 
ulcers  develop. 

'  The  investigations  of  A.  Neisser  have  shown  that  there  is  still  a  possibility  of  in- 
fection from  the  late  lesions  of  syphilis,  for  he  has  been  able  to  produce  typical  primary 
lesions  in  apes  by  inoculating  them  with  tissues  taken  from  the  late  lesions.  The  non- 
ulcerated  gummatous  lesions  were  the  only  ones,  however,  which  gave  positive  results, 
and  this  explains  how  tlie  false  sense  of  security  based  upon  practical  experience  that 
the  guriuiiatous  lesions  in  general  arc  not  infectious  has  arisen. 


SYPHILIS 


459 


Gummatous  Ulcer. — The  ulcer  which  follows  regressive  changes  in 
a  gumma  has  some  very  important  characteristics.  It  is  round,  its 
edges  are  sharply  cut  and  but  little  undermined,  and  its  floor  is  covered 
with  grayish  yellow  necrotic  tissue,  which  is  sometimes  dry  and  at  other 
times  pours  out  a  purulent  secretion.  The  ulceration  extends  deeply 
into  the  firm  tissue  composing  the  nodule.  AVhen  the  entire  lesion  is 
destroyed  by   chronic  suppuration,   and   there  is  no  extension  of   the 


Fig.  194. 


-Ulcerated  Gumma  with  Scalloped  Borders  Due  to  Unequal 
Cicatrization. 


process  from  the  periphery  of  the  ulcer,  healthy  granulating  tissue 
develops  and  the  ulcer  may  heal.  If  healing  occurs  upon  one  side 
of  the  ulcer  and  degenerative  changes  on  the  other,  reniform,  sickle- 
shaped  ulcers  develop.  If  many  ulcers  are  grouped  in  one  region  they 
produce  by  their  confluence  lesions  with  rounded  or  serpiginous  outlines. 

Histology  of  a  Gumma. — Microscopically  a  gmnma  consists  of  granu- 
lation tissue  in  which  are  found  epithelioid  cells  and  an  occasional  giant- 
cell.  The  blood  vessels,  usually  diseased,  are  more  numerous  than  in 
the  tubercle.  The  Avails  of  the  vessels  in  the  gmnma  are  usually  thick- 
ened and  infiltrated  with  round  cells  (vasculitis  and  perivasculitis 
syphilitica) . 

According  to  Kaufmann,  three  zones  may  be  diflVrentiated  when 
the  center  of  a  gumma  becomes  necrotic:  (1)  In  the  center  a  mass 
which  is  caseated  or  has  undergone  fatty  degeneration;  (2)  an  inter- 
mediate zone  composed  of  fibrous  connective  tissue  with  spindle  cells, 
isolated  epitheliod  cells,  and  giant-cells ;  (3)  an  outer  zone  of  prolifer- 
ating connective  tissue,  rich  in  cells  and  blood  vessels. 


460  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

The  alterations  in  the  blood  vessels  differentiate  the  gumma  from  the 
tubercle  and  the  small  round-cell  sarcoma.  In  making  a  differential 
diagnosis,  the  peripheral  parts  of  a  gumma,  in  which  most  of  the  vessels 
lie,  should  be  carefully  examined. 

Diagnosis. — In  considering  the  general  diagnosis  of  syphilis  it  should 
be  mentioned  that  pregnancy  is  often  interrupted  by  syphilitic  disease 
of  the  placenta  or  f(Ptus.  IMiscarriages  are  frequent  in  syphilitic  pa- 
tients and  the  fffitus  is  dead,  macerated,  or  non- viable  when  expelled. 
In  making  a  diagnosis  of  doubtful  lesions  an  accurate  history  as  to 
previous  miscarriages  should  always  be  elicited. 

The  following  lesions  which  occur  in  congenital  syphilis  are  of  great 
diagnostic  importance:  (1)  Interstitial  or  parenchymatous  keratitis, 
which  develops  at  puberty  or  earlier.  At  first  this  is  limited  to  one 
eye,  but  the  other  eye  will  almost  certainly  become  involved  later.  Ul- 
cers do  not  develop  upon  the  cornea,  but  opaicities  develop  as  the  result 
of  the  inflammation.  (2)  Deformities  of  the  teeth,  first  described  by 
Hutchinson,  occurring  most  frequently  in  the  central  upper  incisors, 
but  the  upper  lateral  and  the  lower  incisors  may  also  be  involved.  The 
size  of  the  teeth  diminishes  from  root  to  crown,  and  they  are  often 
separated  from  one  another  by  wide  spaces.  A  notch  occupies  the  center 
of  the  margin  of  the  tooth,  or  they  may  be  "  peg-shaped,"  the  tooth 
narrowing  from  the  root  to  the  crown  and  ending  in  a  free  border. 
These  changes  are  found  in  the  teeth  of  the  second  dentition,  which  may 
appear  early,  be  discolored,  and  soon  crumble  away.  Similar  deformi- 
ties of  the  teeth  occur  in  other  diseases,  associated  with  severe  nutri- 
tional disturbances.  If  deafness  develops  as  the  result  of  involvement 
of  the  internal  ear  and  the  corneal  opacities  and  deformities  of  the 
teeth  are  present,  one  speaks  of  Hutchinson's  triad,  which,  however,  is 
not  infallible  in  making  a  diagnosis  of  syphilis.  Fine  linear  scars  radi- 
ating from  about  the  mouth,  which  follow  the  healing  of  rhagades,  are 
valuable  diagJiostic  signs. 

(a)  SYPHILIS   OF   THE   SKIN 

With  the  exception  of  the  primary  lesions  above  described,  the  ter- 
tiary lesions  of  the  skin  are  of  the  most  interest  to  the  surgeon.  The 
secondary  lesions  are  most  frequently  seen  and  treated  by  the  derma- 
tologist. Clinically  the  symptoms  of  a  gumma  vary,  depending  upon 
whether  it  is  cut;nicous  or  sulx'utnneous. 

Cutaneous  gummata  ai'e  seen  fi((|ii<iitly  in  tlie  early  stages  of  ter- 
tiary syphilis.  Th(\v  jippcnr  ms  (ii'ui,  reddish  brown,  slightly  elevated 
nodules  about  llic  siz(!  of  a  split  pea,  and  are  fr<'<iu<'ntly  arranged  in 
groups.     The  nodules  occui)ying  the  center  of  the  grouj)  may  be  ab- 


SYPHILIS 


461 


sorbed,  or  ulcerate  and  heal,  while  adjacent  healthy  tissue  aljout  the 
periphery  of  the  group  is  invaded  by  new  nodules.  If  the  nodules 
coalesce,  a  diffuse  iniiltration  of  the  skin,  appearing  as  a  red,  hyper- 
teniic  area  with  a  round  or  serpiginous  border,  develops  (papulo-ser- 
piginous  sj^philide.  Fig. 
195).  The  ulcerated  cen- 
ter of  such  a  lesion  may 
heal,  while  the  periphery 
extends. 

The  nodules  and  ulcers 
occurring  in  this  form 
of  syphilis  may  be  very 
similar  to  those  found  in 
lupus,  and  mistakes  in 
diagnosis  are  not  infre- 
quent, especially  when 
the  lesions  occur  upon 
the  face.  Lupus  develops 
much  more  slowly  than 
syphilis,  and  the  nodules 
develop  in  the  scars  re- 
sulting from  the  healing 
of  old  ulcers.  A  tuber- 
culosis lesion  does  not  ex- 
tend so  rapidly  from  the 
periphery  and  does  not 
have  the  serpiginous  out- 
line. The  apple-jellylike 
granulations  so  charac- 
teristic of  lupus  are  not  found  in  the  syphilitic  lesions.  The  deep  sup- 
purating syphilitic  ulcer  with  its  steep,  sharply  defined  borders  differs 
from  the  flat,  somewhat  elevated  ulcer  of  lupus  with  its  apple-jeliylike 
granulations. 

The  subcutaneous  gumma  appears  as  a  round  or  oval  nodule  or 
indefinite  thickening  of  the  subcutaneous  tissue.  It  develops  slowly 
without  giving  rise  to  any  distinct  symptoms,  to  become  as  large  as  a 
walnut  or  largej".  As  the  gunuiia  approaches  the  surface  the  skin  cover- 
ing it  becomes  red  or  reddish  brown.  The  sul)cutaneous  nodules  are 
but  rarely  disseminated  over  the  surface  of  the  body.  The  skin  of  the 
face  (nose,  forehead,  lips)   and  the  thigh  are  most  frequently  involved. 

Sometimes  subcutaneous  gunnnata  do  not  ulcerate,  but  become  ab- 
sorbed. Frequently,  however,  ulcei-ation  occurs  and  the  resulting  lesion 
is  deep,  its  edges  are  sharply  cut,  and  its  base  consists  of  granulation 


Fig.  195. — 1*apii,o-serpigixoi^s  Syphii.idi:  ok  riii;  Skin 
OF  THE  Forehead.  ConipU'te  dcstrvictioii  of  the 
nose  and  upper  lip.  Chronic  ci'dcnui  of  tiie  left  lower 
eyelid. 


462 


WOUND  INFECTIONS  OF  DIFFERENT  ORIGINS 


/ 


S 


\ 


tissue,  although  it  is  sometimes  covered  by  a  characteristic  slough. 
These  ulcers,  in  case  they  do  not  extend  deeply  and  destroy  more  tissue, 
leave  when  they  heal  a  white,  shining,  round  scar.  Extensive  destruc- 
tion occurs  most  frequently  when  these  lesions  develop  upon  the  face, 
— ^.__^  where  not  only  the  lips  and  eye- 

lids, but  also  the  entire  nose 
with  its  cartilaginous  and  bony 
framework  may  be  destroyed. 
The  scalp  and  skin  of  the  fore- 
head may  be  transformed  into 
a  large,  shining,  flat,  firmly  at- 
^VL-^^M         rf'"\»-i,      '  tached    scar,    throughout    which 

r<4   '-'^^Mf^LJ    ' ^^'^^'^^^^^y^'-  ■  rf  appear    swollen    areas    of    skin 

^   ■      •  '^^  '^1  (Fig.  196).    In  severe  cases  only 

the  unprotected  bulbs  of  the  eyes 
and  the  openings  which  indicate 
the  position  of  the  nose  and 
mouth  remain  within  the  radially 
arranged  masses  of  scar  tissue. 
In  rare  cases  a  carcinoma  devel- 
ops upon  a  syphilitic  ulcer;  then 
the  syphilitic  ulcer  assumes  the 
characteristics  of  a  carcinomatous 
ulcer. 

Differential  Diagnosis.  —  The 
diagnosis  of  subcutaneous  gum- 
mata  and  the  ulcers  developing 
from  them  is  not  difficult,  especially  if  there  are  other  symptoms  of 
syphilis.  As  a  rule,  the  lesions  are  so  characteristic  that  there  is  no  dif- 
ficulty in  making  the  diagnosis,  even  when  no  other  lesions  are  present. 
A  gumma  develops  much  more  slowly  than  the  nuiltiple  sarcomas 
of  the  skin,  which  are  frequently  bluish  in  color,  as  they  often  contain 
pigment  (melano-sarcoma),  and  the  acute  painful  nodules,  accompanied 
by  fever,  which  develop  in  erythema  nodosum.  It  may  be  very  difficult 
to  differentiate  between  a  non-ulcerated  gunnna  and  the  tumors  which 
develop  in  mycosis  fungoides. 

A  solitary  syphilitic  ulcer  may  resemble  very  closely  a  carcinoma  of 
the  skin.  In  a  syphilitic  lesion  there  will  be  no  enlargement  of  the 
adjacent  lymph  nodes  unless  there  is  secondary  infection,  and  even  then 
the  lymph  nodes  will  not  be  indurated  as  they  are  when  infiltrated  with 
carcinoma  cells.  The  borders  of  the  syphilitic  ulcer  are  not  indurated 
and  craterlike  as  the  borders  of  the  carcinomatous  ulcer  are.  The  floor 
of  a  carcinomatous  ulcer,  from  which  comedolike  masses  may  be  squeezed 


Fig.  196. — A  Thirty  Year  Old  Woman  Infect- 
ed WITH  Syphilis.  Extensive  destruction  of 
the.skin  and  bones  of  the  face.  Defects  of  lids, 
cheeks  and  lips  repaired  by  non-pedunculated 
cutis  flaps.  Saddle-nose  with  perforation,  an- 
chylosis of  the  temporo-mandibular  joint. 


SYPHILIS  463 

nut,  is  indurated  and  fissured  and  bleeds  easily,  while  the  floor  of  a 
syphilitic  ulcer  is  less  hard,  contains  caseous,  necrotic  tissue,  and  bleeds 
only  where  healthy  granulations  have  developed. 

Demonstration  of  the  bacilli  of  glanders  by  microscopic  examination 
or  animal  experiments,  and  the  inefficiency  of  anti-syphilitic  treatment 
prevent  confusion  with  chronic  glanders.  The  demonstration  of  bacilli 
in  the  nodules  and  ulcers  of  leprosy  and  a  number  of  other  charac- 
teristics guard  against  mistakes  in  diagnosis  in  countries  where  both 
leprosy  and  syphilis  occur.  Actinomycosis  of  the  skin  is  rare,  and  the 
ulcers  developing  in  this  disease  resemble  those  of  tuberculosis.  From  the 
fistuUi3  which  form  the  sulphur  yellow  bodies,  composed  of  colonies  of 
ray  fungi,  are  discharged. 

Blastomycetic  dermatitis  may  be  mistaken  for  a  syphilitic  skin  lesion 
(see  p.  391). 

In  all  doubtful  cases  an  energetic  anti-syphilitic  treatment  should 
be  instituted.  If  there  is  no  improvement  after  two  weeks,  the  lesion 
is  not  of  a  syphilitic  nature.  If  there  is  a  question  as  to  malignancy, 
operative  removal  should  no  hmger  be  postponed  after  a  trial  treat- 
ment of  this  duration. 

Treatment. — The  gummata  and  ulcers  heal  rapidly  when  early  and 
energetic  anti-syphilitic  treatment  is  instituted.  The  local  treatment 
consists  of  the  application  of  blue  or  white  precipitate  ointment,  curet- 
ting of  the  ulcers,  and  incision  and  curettage  of  the  softened  nodule. 
Repair  is  often  hastened  by  local  treatment.  Plastic  operatioils  are 
often  indicated  to  correct  the  deformities  resulting  from  the  contrac- 
tion of  scars  upon  the  face. 

(b)  SYPHILIS   OF   MUCOUS  MEMBRANES 

Besides  the  primary  lesion,  which  occurs  most  frequently  as  an 
indurated  ulcer  upon  the  margin  of  the  lips,  the  tonsils,  the  gums,  and 
the  tongue,  and  can  scarcely  be  mistaken  for  any  other  lesion,  because 
of  its  rapid  development  and  the  early  and  extensive  involvement  of 
adjacent  lymph  nodes,  there  are  a  number  of  lesions  of  the  mucous 
membranes  (especially  of  the  mucous  membi-ane  of  the  mouth  cavity) 
which  develop  in  the  second  stage  of  the  disease.  These  develop  at  the 
same  time  as  the  eruption  or  recur  independently.  Sharply  delimited 
erythematous  areas,  round  and  flat,  pearl  gray  or  bluish  white  papules, 
and  suppurating  ulcers  and  rhagades,  the  floors  of  which  are  covered 
with  necrotic,  caseous  tissue,  develop  upon  the  buccal  nnicous  membrane 
during  this  stage.  They  correspond  to  the  macules,  papules,  and  ulcers 
which  develop  in  the  skin. 

Rhagades  develop  most  frequently  about  the  angles  of  the  mouth, 


464  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

papules  upon  the  tongue,  and  the  lesions  which  are  known  as  syphilitic 
angina  upon  the  soft  palate  and  in  the  pharynx.  In  syphilitic  angina 
the  uvula  and  the  pillars  of  the  fauces  become  reddened  and  congested. 
The  hyperaimia  is  semicircular  in  outline,  and  is  sharply  delimited 
from  the  healthy  mucous  membrane  anteriorly,  and  can  be  easily  dif- 
ferentiated in  this  way  from  the  indistinct  redness  of  the  ordinary 
angina,  which  gradually  fuses  with  that  of  healthy  mucous  membranes. 
Sometimes  the  tonsils  become  swollen,  painful,  and  covered  with  a  gray 
membrane  or  ulcerated,  the  lesions  resembling  somewhat  those  occurring 
in  faucial  diphtheria.  In  syphilis,  however,  there  is  no  fever  and  in- 
spection will  reveal  grayish  white,  opalescent  papules  (plaques  opa- 
lines) upon  the  soft  palate  and  the  posterior  wall  of  the  pharynx  and 
other  lesions  of  syphilis. 

Gummatous  lesions  develop  most  frequently  in  the  mucous  mem- 
branes of  the  mouth,  nose,  pharynx,  larynx,  and  rectum.  The  process 
may  extend  deeper,  involving  cartilage  and  bone  and  producing  exten- 
sive destruction  of  the  tissues  involved.  Perforation  of  the  soft  and 
hard  palate,  of  the  septum  and  bridge  of  the  nose,  and  cicatricial 
stenosis  of  the  larynx  (following  gummatous  ulcers  upon  the  arytenoid 
cartilages,  in  the  true  and  false  vocal  cords)  and  of  the  rectum  are  fre- 
quent. Disease  of  the  nasal  mucous  membrane  is  indicated  by  a  foul- 
smelling,  purulent  discharge  {ozcena)  ;  then  the  bridge  of  the  nose 
gradually  sinks  in,  as  its  bony  framework  is  destroyed  by  the  syphilitic 
osteitis.  If  this  destructive  process  extends  from  the  nose  or  pharynx 
to  the  base  of  the  skull,  a  fatal  meningitis  may  develop. 

The  diagnosis  of  a  lesion  resulting  from  ulceration  of  gummata  of 
the  mucous  membranes  is  not  difficult  when  the  disease  is  well  advanced. 
The  tumorlike  gummata  developing  in  the  nniscles  of  the  tongue,  which 
frequently  ulcerate  but  little,  may  be  mistaken  for  carcinoma,  but  the 
induration  and  swelling  of  adjacent  lymph  nodes  (the  rule  in  carcinoma) 
do  not  occur  with  gummata.  In  doubtful  cases  a  small  piece  of  the 
diseased  tissue  should  be  removed  and  a  microscopic  examination  made. 
Frequently  the  other  mistake  is  made :  a  carcinoma,  in  spite  of  the 
metastases  into  lymph  nodes,  is  regarded  as  a  gumma,  and  anti-syphi- 
litic treatment  is  continued  until  the  carcinomatous  infiltration  has  be- 
come so  extensive  that  operative  removal  of  the  disease  is  out  of  the 
question. 

Tuberculous  ulcers  of  the  mucous  membranes  ai-e  flatter  than  the 
gummatous  and  their  borders  are  not  shar])ly  cut,  but  are  irregular 
and  ragged,  and  the  floor  of  the  ulcer  contains  apple-jellylike  granu- 
lations. 

General  anti-syphilitic  treatment  should  be  instituted,  and  a  nasal 
douche  or  a  mouth-wash,  depending  upon  the  position  of  the  lesion, 


SYPHILIS  465 

of  some  mild  antiseptic  solution  (potassium  permanganate,  acetate  of 
aluminum,  boric  acid,  etc.)  should  be  used.  Rapid  healing  follows  a 
course  of  treatment  with  iodid  of  potassium,  if  secondary  infection  of 
the  specific  osteitis  has  not  already  developed.  Then  it  may  be  impos- 
sible to  prevent  perforation  of  the  palate,  destruction  of  the  nasal  bridge, 
etc. 

(c)  SYPHILIS  OF   MUSCLE 

Rheumatic  muscle  pains,  the  exact  nature  of  which  is  not  known, 
may  occur  in  the  earliest  stages  of  syphilis,  especially  in  the  eruptive 
stage.  Not  infrequently  muscle  contractures  develop  in  the  first  year 
after  the  infection.  The  biceps  brachii  and  other  flexors,  occasionally 
the  triceps  brachii,  are  involved.  The  contractures  develop  very  slowly, 
sometimes  with  little,  sometimes  with  severe  pain,  and  may  disappear 
spontaneously.  They  are  usually  the  result  of  a  fibrous  or  a  gummatous 
myositis. 

In  the  difi'use  syphilitic  or  fibrous  myositis  which  develops  some 
years  after  infection,  usually  one,  more  rarely  many,  muscles  are  in- 
volved. Those  most  frequently  involved  are  the  masseter,  the  muscles 
of  the  calf  and  arm,  the  sterno-eleido-mastoid,  and  the  sphincter  ani 
externus.  The  entire  muscle  swells  acutely,  sometimes  more  chronically, 
as  a  result  of  the  interstitial  inflammation,  and  becomes  hard  and  pain- 
ful upon  pressure  and  movement.  As  a  result  contractures  develop 
(inflammatory  lockjaw,  wryneck,  etc.)  and  normal  muscular  move- 
ments are  interfered  with. 

According  to  Honsell  and  0.  Busse,  this  form  of  myositis  does  not 
difl:'er  histologically  from  any  other  form  of  interstitial  myositis.  In 
recent  cases,  healing  with  restoration  of  function  follows  anti-syphilitic 
treatment  continued  for  some  weeks.  In  other  cases  the  muscle  fibers 
degenerate  and  the  entire  muscle  becomes  shortened  and  transformed 
into  a  thin,  connective-tissue  strand.  This  happens  most  frequently 
when  small  gummata  develop  in  association  with  the  difi'use  infiltration 
(cicatricial  gummata). 

The  muscle  gummata  belong  almost  exclusively  to  the  late  forms  of 
syphilis,  developing  from  ten  to  thirty  years  after  the  infection. 

Circumscribed,  firm  nodules,  which  may  reach  considerable  size,  de- 
velop in  the  belly  of  the  muscle  or  near  its  origin  or  insertion.  Some- 
times one,  sometimes  many  nodules  develop  in  a  nuiscle.  Not  infre- 
quently a  number  of  difl'erent  muscles  are  involved  simultaneously, 
sometimes  symmetrical  muscles.  These  nodules  develop  most  frequently 
in  the  sterno-eleido-mastoid,  in  the  nuiscles  of  mastication,  in  those  about 
the  shoulder,  of  the  upper  arm,  the  thigh,  the  calf,  and  the  gluteal 
region,     Gummata  in  the  muscles  of  the  tongue  are  frequent. 


466  WOUND   INFECTIONS   OF   DIFFERENT  ORIGINS 

When  it  has  reached  a  certain  size  (as  a  rule,  that  of  a  hazelnut)  a 
nodule  which  may  have  given  rise  to  no  symptoms  is  accidentally  discov- 
ered. Often  it  is  first  noted  after  an  injury,  and  in  some  cases  probably 
a  trauma  determines  the  development  of  the  lesion.  A  large,  single,  cir- 
cumscribed gumma  can  be  palpated  much  more  easily  than  multiple 
small  gummata  situated  close  together  or  in  an  extensively  inflamed 
muscle.  They  feel  larger  in  contracted  than  relaxed  muscles  and  move 
with  the  muscle  until  they  degenerate  and  contract  adhesions  with 
neighboring  structures  or  discharge  externally.  If  the  nodules  do  not 
disappear  after  some  time,  leaving  a  scar  in  the  muscle  which  is  ad- 
herent to  the  skin,  large  abscesses  which  may  rupture  easily  or  deep 
ulcers  with  large  recesses  develop.  Both  may  cicatrize,  but  there  is 
always  a  destruction  of  a  large  part  of  the  muscle. 

The  diagnosis  of  a  gumma  in  a  muscle  which  has  not  ruptured  ex- 
ternally is  always  difficult  unless  the  nodule  is  situated  in  some  muscle 
commonly  affected,  such  as  the  sterno-cleido-mastoid  or  muscles  of  the 
tongue.  Small  nodules  may  be  confused  with  cysticercus  or,  occurring 
in  the  abdominal  muscles,  with  desmoids.  Softened,  rapidly  growing 
gummata,  attached  to  surrounding  structures  (bone,  blood  vessels,  skin), 
may  be  regarded  as  soft,  rapidly  growing  sarcomata.  Nodules  which 
go  on  to  abscess  formation  resemble  clinically  primary  or  secondary 
tuberculosis  of  muscle  (especially  that  secondary  to  tuberculosis  of 
the  chest).  Pus  discharged  from  syphilitic  lesions  is  often  steel  blue  in 
color  and  thick  (von  Bramann)  ;  frequently,  however,  it  cannot  be  dis- 
tinguished from  ordinary  tuberculous  pus. 

The  diffuse,  boardlike  infiltration  of  the  muscles  of  mastication  re- 
sembles that  occurring  in  facial  actinomycosis.  An  impulse  may  be 
transmitted  to  a  gummatous  abscess  lying  over  a  large  vessel  and  an 
aneurysm  may  be  simulated.  An  ulcerated  gumma  of  the  tongue  may 
be  mistaken  for  a  superficial,  less  rapidly  growing  carcinoma.  The 
syphilitic  nature  of  such  a  lesion  may  be  recognized,  even  when  there 
are  no  other  symptoms  of  the  disease,  by  the  absence  of  the  character- 
istics of  carcinoma,  the  fact  that  the  lesion  is  composed  of  many  nodules, 
its  painless  development,  and  the  diminution  in  size  under  anti-syphilitic 
treatment. 

A  complete  but  slow  absorption  of  diffuse  syphilitic  muscle  infiltra- 
tions and  gummata  follows  energetic  anti-sypliilitic  treatment.  In  doubt- 
ful cases  in  whicli  it  is  possible  that  a  malignant  growth  exists,  iodid  of 
potassium  should  not  be  continued  until  the  growth  becomes  inoperable. 
If  there  is  no  diminution  in  the  size  of  the  lesion  after  two  weeks,  an 
operation  is  indicated.  It  is  often  impossible  to  differentiate  between  a 
gumma  and  a  sai-coma  even  after  they  are  incised,  as  they  are  very 
similar  in  appearance.     Even  a  microscopic  diagnosis  may  be  difficult. 


SYPHILIS  467 

Cuueiform  excision  hastens  the  healing  of  large  gummata.  Ulcers 
resulting  from  the  degeneration  of  gunnnata  should  be  dressed  aseptic- 
ally.     Dressings  of  mercury  ointment  may  be  used  to  advantage. 

(d)  SYPHILIS   OF   THE   LYMPHATIC   VESSELS  AND   NODES   AND 
OF   THE   BLOOD   VESSELS 

Syphilis  of  the  lymphatic  vessels  is  of  little  surgical  importance. 
Frequently  red  streaks  develop  in  the  skin  covering  the  dorsum  of  the 
penis,  secondary  to  the  initial  sclerosis,  and  in  the  skin  of  the  forearm 
or  about  the  angle  of  the  jaw  when  the  chancre  is  extra-genital.  The 
enlarged  and  indurated  lymphatic  vessels,  which  gradually  subside,  may 
be  palpated  beneath  these  streaks. 

The  rare  gummatous  lymphadenitis  is  the  most  important  syphilitic 
lesion  of  lymph  nodes,  as  it  is  frequently  mistaken  for  other  patho- 
logic conditions.  The  painless  swelling  of  the  lymph  nodes  adjacent 
to  the  primary  lesion  which  develops  in  from  one  to  three  weeks  after 
the  chancre,  and  the  general  enlargement  of  the  nodes  beginning  with 
the  general  infection  in  the  eruptive  stage  are  very  characteristic. 
The  nodes  are  painless,  as  large  as  a  hazelnut  or  cherry,  never  larger 
than  a  bean,  move  freely  under  the  skin  and  do  not  suppurate  unless 
there  is  a  secondary  infection.  The  enlargement  of  the  nodes  may  per- 
sist for  years. 

In  gummatous  lymphadenitis  there  develop  slowly,  most  frequently 
in  the  submaxillary  and  inguinal  regions,  hard,  nodular  masses  which 
may  become  as  large  as  a  hen's  egg.  These  may  be  mistaken  for  neo- 
plasms, for  example,  of  the  submaxillary  gland ;  for  hard,  tuberculous 
glands,  if  they  become  adherent  to  surrounding  structures,  soften  and 
discharge  externally;  for  malignant  growths,  actinomycosis  or  tuber- 
culous abscesses.  Only  Avhen  deep  ulcers  form  do  the  unmistakable 
signs  of  the  specific  nature  of  the  disease  become  pronounced.  If  the 
destruction  of  tissue  is  extensive,  fatal  hjemorrhages  may  follow  the 
erosion  of  large  arteries  (innominate  vein,  femoral  artery)  (von  Es- 
march).  The  enlarged  nodes  gradually  subside  after  an  energetic  anti- 
sj'philitic  treatment.  Healing  may  be  hastened  by  the  extirpation  of 
degenerated  glands. 

A  proliferation  and  cellular  infiltration  of  the  walls  of  the  arteries 
with  a  tendency  to  obliteration  of  the  lumina  (arteritis  syphilitica  ob- 
literans) may  develop  in  the  late  stages  of  the  disease.  Smaller  vessels 
— for  example,  the  basilar  artery — may  be  transformed  into  a  fibrous 
cord.  These  changes  are  not  associated  with  gummata  or  syphilitic 
nodules  in  the  vessel  wall. 

Although  these  arterial  changes  are  not  of  a  specific  nature,  they 


468 


WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 


may  be  differentiated  from  other  forms  of  arterio-sclerosis.  ["  The 
process  differs  from  simple  atheroma  (1)  in  attacking  small  arteries, 
(2)  in  affecting  the  whole  circumference  of  the  vessel  and  not  merely 
patches,  (3)  the  newly  formed  tissue  becomes  vascular  and  does  not 
undergo  fatty  degeneration,  and  (4)  it  leads  to  narrowing  or  occlusion 
of  the  vessel  rather  than  to  weakening  and  dilatation." — Rose  and  Car- 
less,  "  Manual  of  Surgery,"  p.  300.] 


/'."T ;  1 


<:^ 


Fig.  197. — Syphilitic  Hyimouostosis  of  the  TiniA.  a,  Roughened  surface  of  the  bone 
covered  with  osteophytes;  b,  longitudinal  section  of  the  bone.  Medullary  cavity 
obliterated.      In  the  center  o.steosclcrosis,  above  and  below  osteoporosis. 

The  changes  occur  freriucntly  in  the  terminal  branches  of  the  inter- 
nal carotid  artery.  Different  forms  of  paralysis  may  follow  the  occlu- 
sion of  these  vessels. 


SYPHILIS  469 

Similar  changes  are  found  in  the  arteries  and  veins  which  supply 
a  gumma,  and  regressive  changes  in  a  gunnna  follow  the  obliteration 
of  these  vessels.     Only  rarely  do  gummata  develop  in  the  arterial  wall. 

(e)  SYPHILIS   OF   BONE 

The  gumma  is  the  most  important  specific  lesion  of  bone.  It  de- 
velops in  the  periosteum  or  medulla  or  extends  to  the  bone  from  adja- 
cent tissues.  The  gunnna  is  one  of  the  late  lesions  of  syphilis,  but  may 
develop  during  the  eruptive  stage  of  the  severer  forms  of  the  disease. 
In  the  early  period  a  mild  form  may  attack  the  periosteum  only.  It 
has  not  been  demonstrated  that  trauma  is  a  predisposing  factor  in  the 
development  of  an  osteal  gunnna,  although  it  is  often  claimed  to  be  an 
etiological  factor. 

Syphilitic  Osteosclerosis  and  Osteoporosis. — During  the  development, 
involution,  or  suppuration  of  an  osteal  gumma,  two  pathological  proc- 


Fk;.  198. — Syphilitic  Periostitis  of  the  Radius.     Congenital  Syphilis. 
Bo}'^  seven  years  of  age.      (From  Professor  Bevan's  Surgical  Clinic.) 

esses,  destructive  and  constructive,  are  always  combined.  The  granu- 
lation tissue  of  the  gumma  infiltrates  the  bone,  causing  caries  or 
necrosis,  and  at  the  same  time  the  surrounding  tissue  is  stimulated  to 
the  production  of  new  bone.  The  surface  of  the  diseased  bone,  there- 
fore, appears  irregular,  roughened,  and  eroded,  but  the  bone  as  a  whole 
may  be  larger  than  is  normally  the  case.  Osteophytes  and  partial  hyper- 
ostoses develop  as  the  result  of  this  new  bone  formation.     If  the  entire 


470 


WOUND   INFECTIONS   OF    DIFFERENT   ORIGINS 


bone  is  involved,  it  may  become  hardened  and  thickened  (osteosclerosis, 
eburnatio),  or,  as  the  result  of  the  excessive  hicunar  absorption,  it  may 
become  rarefied  (osteoporosis)  ;  fractures  follow  this  abnormal  fragility 
(osteopsathyreosis) . 

Syphilitic  Periostitis. — In  both  congenital  and  acquired  sj^philis, 
periostitis  frequently  develops  during  the  eruptive  stage.  It  develops 
simultaneously  in  many  different  bones,  most  frequently  upon  the 
frontal  and  parietal,  the  tibia,  sternum,  and  clavicle.  A  flat,  elastic 
nodule,  the  size  and  shape  of  an  hour-glass  and  covered  by  normal 
skin,  develops  upon  the  surface  of  the  bone  involved.  Only  when  such 
a  nodule  attains  considerable  size  does  the  skin  covering  it  become  red- 
dened and  oedematous. 

Macroscopic  Appearance  of  a  Gumma  of  Bone. — Incisions  made  in 
gummata  under  a  wrong  diagnosis  have  revealed  a  thick,  tenacious  fluid ; 

for  in  this  form  of  gum- 
mata a  gelatinous  tissue  de- 
velops in  the  inner  layers  of 
the  periosteum,  from  which 
processes  extend  into  the  di- 
lated Haversian  canals.  Ac- 
cording to  von  Bergmann, 
the  periostitis  developing  in 
the  earlier  stages  of  syphilis 
cannot  be  differentiated  from 
the  periosteal  gumma,  and 
the  former  is  to  be  regarded 
as  a  mild  form  of  the  latter. 
The  small  inflltrations  disap- 
pear rapidly  without  ulcerat- 
ing or  suppurating,  leaving 
but  little  trace  of  previous 
involvement  of  the  bone.  A 
slight  depression  in  the  sur- 
face of  the  bone,  the  result 
of  a  caries  sicca,  may  re- 
main for  some  time  and  in- 
dicate the  location  of  the 
previous  lesion. 
Giimmalous  Periostitis  Developing  in  the  Late  Stage  of  Syphilis.^ 
The  gummatous  periostitis  developing  in  the  late  stage  of  syphilis  is 
charactej'ized  by  its  slow  growth,  its  chronicity,  and  the  size  which  the 
lesions  attain.  The  gumma  develops  in  the  inixer  layers  of  the  perios- 
teum and  passes  along  the  blood  vessels  of  the  Haversian  system  to 


/■ 


Fig.  199. — Large  Syphilitic  Ulcijhs  of  thk  Head 
which  ff)i>loaved  the  breaking  down  of  peri- 
OSTEAL Gummata  involving  the  Frontal  and 
Parietal  Bones. 


SYPHILIS  471 

penetrate  the  bone.  Flat,  cireumseribecl,  only  sliglitly  painful  nodules 
(called  tophi)  develop  simultaneously  in  dil'tVi'ent  parts,  most  frequently 
upon  the  frontal  and  parietal  bones,  the  ribs,  sternum,  clavicle,  and 
bones  of  the  foi'earm.  These  nodules  vary  in  sizc^  from  that  of  a  dollar 
to  that  of  a  man's  list,  and  in  the  beginning-  have  an  elastic  feeling  and 
are  covered  by  normal  skin.  They  soon,  however,  undergo  a  number  of 
regressive  changes.  After  a  caseous  or  fatty  degeneration  of  the  tissue 
composing  it,  the  gunnna  (nther  becomes  absorbed  or  suppurates.  If 
the   nodule   becomes   absorbed,   its   center   gradually   softens   and  sinks 


Fig.  200. — Gummatous  Periostitis  axd  Osteitis  with  Necrosis  and  a  Defect  in  the 

Skull. 

until  finally  the  entire  mass  disappears  completely.  A  depression  sur- 
rounded by  a  wall-like,  irregular  border,  the  result  of  the  ossifying 
periostitis,  remains  after  a  gumma  is  absorbed.  If  suppuration  occurs, 
fluctuation,  indicative  of  softening,  becomes  much  more  distinct  and  the 
skin  covering  the  lesion  becomes  thinned  and  reddened.  If  the  liquefied 
mass  is  not  removed  by  aspiration  or  incision,  the  skin  breaks  down  and 
a  large  ulcer  forms.  Large  ulcers  which  discharge  a  mucoid,  often  foul- 
smelling,  pus  in  which  may  be  found  caseous  particles  and  necrotic 
strands  of  tissue  follow  the  regressive  changes  in  these  lesions.  The 
destructive  lesion  gradually  extends  until  the  surface  of  the  bone  is 
bared  and  denuded ;  even  dead  bone  may  be  felt  in  the  floor  of  the  ulcer. 
The  borders  of  such  a  lesion  are  separated  from  the  subjacent  tissues 


472  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

by  the  yellow  cicatricial  tissues  of  the  gumma.  A  thin  layer  of  bone, 
corresponding  in  size  to  the  area  involved  in  the  gummatous  osteitis, 
becomes  necrotic.  Round,  disklike,  often  perforated  pieces  of  sclerotic 
bone  gradually  become  separated  from  the  thickened  surrounding  bone. 
Repair  begins  with  the  formation  of  healthy  granulation  tissue,  and  is 
completed  by  the  formation  of  a  scar,  which  becomes  firmly  attached 
to  the  underlying  bone.  The  surface  of  the  bone  is  changed ;  it  is 
thickened  and  contains  nodules  and  depressions.  Where  many  perios- 
teal gunnnata  develop  at  the  same  time  and  extend  deeply  into  the 
underlying  bone,  as  is  frequently  the  case  in  the  skull,  hyperostoses  of 
considerable  size  remain  after  the  lesions  heal. 

Gummatous  Osteitis. — Gummatous  osteitis  is  frequently  associated 
with  periostitis,  being  secondary  to  it.     If  suppuration  accompanies  this 

form  of  osteitis,  as  frequently 
occurs  when  the  hard  palate, 
the  nasal  and  facial  bones 
are  involved,  the  bone  may 
be  completely  destroyed. 
Perforation  of  the  palate  and 
syphilitic  saddle-nose,  result- 
ing from  destruction  of  the 
bony  framework  and  sub- 
sequent sinking  in  of  the 
bridge  of  the  nose,  are  the 
most  common  and  well- 
known  examples  of  this  form 
of  osteitis  (Fig.  201).  The 
only  nasal  deformity  that 
^   -s*  ^^^^^H  resembles  this  at   all  is  the 

traumatic  saddle-nose  which 
follows  infected  compound 
fractures  of  the  nasal  bones. 
Osteal   giimmata   and   osteo- 

FiG.  2()l.-8YPnn.,Tic  SAnni,i.-NO.sK.  P^^yteS    developing    upOU    the 

inner  surface  of  the  skull 
bones  or  growing  into  the  oi'bit  may  exert  pi-essure  upon  the  cortex  of 
the  brain  or  the  optic  nerve  and  prove  dangerous  in  this  way. 

The  surface  of  bone  is  frequently  involved  secondai'ily  bygummata 
of  the  skill  and  soft  tissues.  The  frontal,  parietal,  and  facial  bones  are 
often  destroyed  })y  this  chronic  inHniiimatoiy  ])rocess  or  transformed 
into  an  nnsiglitly,  shapel(>ss  mass  of  bone. 

Gummatous  Osteomyelitis. — Tn  giiiiiinatous  osteomyelitis,  which  is 
rarer  than  gummatous  osteitis,  grayish  red,  gelatinous  foci,  varying  in 


SYPHILIS 


473 


size  from  a  pea  to  a  nnt,  develop  in  the  marrow  of  hone  and  in  the 
niodiilhiry  spaces  of  tlie  sponu,iosa  and  dii)loe.  Tliese  foci,  wliich  some- 
times cause  no  symptoms,  at  other  times  excruciating  pain  (dok)res  os- 
teoscopi),  later  undergo  fatty  changes 
and  become  yellowish  and  friable. 

The  bone  infiltrated  by  these  foci, 
which  are  frequently  multiple,  gradu- 
ally liquefies,  while  the  bone  surround- 
ing them  becomes  thickened  and  scler- 
otic. If  many  foci  coalesce,  small  or 
larger  sections  of  the  bone  may  be  de- 
prived of  their  nourishment  and  become 
necrotic.  A  syphilitic  sequestrum  sepa- 
rates slowly,  frequently  lying  bare  in 
a  wound  for  years  without  being  com- 
pletely separated  from  the  surround- 
ing involucrum.  The  slow  separation 
— that  is,  formation  of  the  line  of 
demai'cation — is  due  to  the  slight  vas- 
cularity and  the  sclerosis  of  the  sur- 
rounding bone. 

The  frontal  and  parietal  bones  are 
most  frequently  involved  in  this  form 
of  the  disease,  the  lesion  beginning  either  upon  the  inner  or  outer  sur- 
face of  the  bone  and  gradually  extending  through  it.  The  macerated 
skull  has,  therefore,  in  spite  of  large  and  extensive  hyperostoses,  a 
perforated,  wormeaten  appearance.  If  suppuration  occurs,  the  clini- 
cal picture  resembles  that  following  suppuration  and  rupture  of  a  peri- 
osteal gunnna. 

When  repair  occurs,  the  irregular, 
ragged,  disklike  se(iuestra,  which  some- 
times may  be  very  large,  are  slowly 
separated  from  the  sclerotic  bone  sur- 
rounding them.  Large  defects,  which 
may  extend  to  the  dura,  result  from 
the  separation  of  such  sequesti'a. 

Syphilitic  Dactylitis. — Short,  hollow 
bones,  when  a  gunnna  develops  within 
their   interior,    become    expanded    and 
thickened  as  the  result  of  the  growth 
of  the  gumma  and  the  accompanying  periostitis.     Involvement  of  the 
metacarpal  and  metatarsal  bones  and  phalanges  gives  rise  to  the  clini- 
cal picture  of  spina  ventosa.     Not  infrequently  the  same  flasklike  ex- 
31 


Fig.  202. — Defect  in  the  Skull  caused 
BY  A  Gummatous  Osteomyelitis. 
(After  Heineke.) 


FiCx.  203.- 


-Congenital  Syphilitic  Dac- 
tylitis. 


474 


WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 


rn 


pansion  occurs  as  in  tuberculosis.  This  form  of  the  disease,  called 
syphilitic  dactylitis  by  Liicke,  may  be  jarimary  or  secondary  to  gum- 
matous inflammation  of  the  surrounding  soft  tis- 
sues. Ulcers  and  fistuUe  may  result  from  regres- 
sive changes  in  the  gummata,  and  entire  necrotic 
phalanges  may  be  extruded  or  absorbed  without 
accompanying  suppuration.  These  changes  occur 
in  both  acquired  and  congenital  syphilis.  In  the 
latter  the  lesions  are  frequently  multiple  and  do 
not  rupture  externally   (Ilochsinger). 

Syphilitic  caries  of  the  vertebrae  is  rare.     If 
this  develops  in  the  upper  part  of  the  spinal  col- 
■"^j  umn,  sudden  and  dangerous  falling  together  of 

^■^M         ^^^  bodies  of  the  vertebrae  may  occur. 
1*7^^  The   spongy  articular   ends  of  the   diaphysis 

are  but  rarely  involved.  They  may  become  ex- 
panded, when  diseased,  to  resemble  a  tumor.  The 
ligaments  and  cartilages  are  destroyed  when  the 
process  ruptures  into  the  joint  cavity.  It  is 
sometimes  difficult  to  differentiate  this  lesion  from 
a  central  sarcoma  or  a  chronic  suppurative  osteo- 
myelitis. 

The  diaphyses  of  long,  hollow  bones  become 
diseased  more  frequently  than  the  articular  ends, 
the  bones  of  the  leg  and  forearm  being  most 
commonly  attacked.  The  central  gumma  pro- 
duces a  slowly  developing  fusiform  expansion  of 
the  bone.  The  bone  is  infiltrated  by  the  granu- 
lation tissue  of  the  gumma  and  becomes  porous, 
[    f  and  its  resistance  is  so  reduced  that  pathological 

fractures  may  occur,  notwithstanding  the  fact 
that  the  bone  surrounding  such  a  lesion  be- 
comes thickened  and  sclerotic  (von  Volkmann. 
Fig.  204). 

Diifuse  Syphilitic  Periostitis  and  Gummatous 
Osteomyelitis. — licsidcs  the  localized  giunmatous 
periostitis  and  osteomyelitis  thei-e  is  also  a  diffuse 
form.  This  form  of  the  disease,  usually  running 
its  course  with  suppuration,  may  cause  exten- 
sive destruction  of  the  bones  of  the  skull;  in  the 
long  bones,  especially  in  those  of  the  forearm 
and  leg,  it  may  produce  large  hyperostoses.  The 
bone   involved   may   gradually   Ijecome  thickened. 


Sl"^"  ' 


Fig.  204. — Pathological, 

Fracture  OF  THE  Shaft 
OF  THE  Radius.  Speci- 
men removed  from  ;i  man 
fifty-six  yearsof  ii^e,  who 
had  suffered  from  syph- 
iUs  for  sixteen  years. 
I'Vacture  occurred  while 
the  pal  ieiit  was  support- 
ing himself  upon  f  hearni 
while  turuinf!;ov(T  in  bed. 
A  douj;;hy,  fusiform  ex- 
pansiciM  of  theboiiecotild 
be  palpated,  'i'he  skin 
covering  the  diseased 
bone  was  perfectly  nor- 
mal. (From  Volk- 
mann's  "  Diseases  of  the 
Organsof  Locomotion.") 


SYPHILIS 


475 


sclerotic,   and  heavier  than  normal,  or  as  a   result  of  the  osteoporosis 
more  fragile  and  lighter. 

If  the  gummatous  inflammation  occurs  in  early  childhood  (the  dis- 
ease being  acquired  early  or  being  congenital)   a  characteristic  deform- 


FiG.  205. — Syphilitic  Osteitis  Deformans  (Thirty  Year  Old  Male  Patient)  with 
Roentgen-ray  Picture. 

ity  develops  in  the  bones  of  one  or  both  legs.  This  form  of  syphilis 
of  bones  was  first  described  by  Fournier  as  osteitis  deformans  sijphi- 
titiea.  The  til)ia  becomes  lengthened,  eurv(>d  forward,  and  thickened, 
and  a  prominence  develops  upon  the  anterior  surface  which  becomes 
more  prominent  than  the  calf  of  the  leg.  The  "  saber-sheath  "  de- 
formity of  the  tibia  is  due  to  a  thickening  and  lengthening  of  the  bone 


476  WOUND   INFECTIONS  OF   DIFFERENT  ORIGINS 

as  a  result  of  the  inflammation.  The  curving  of  the  tibia  forward  is 
not  to  be  regarded  as  static  and  compensatory  (Schuchardt),  but  is  due 
to  the  lack  of  corresponding  increase  in  the  length  of  the  flbula  and  to 
the  traction  exerted  by  the  muscles  attached  to  the  latter  (Weiting).  A 
similar  deformity  may  occur  in  riclcets,  but  in  this  disease  the  epiphysis 
will  be  involved  and  rachitic  changes  will  be  present  in  other  bones 
(Fig.  205). 

Osteochondritis  Syphilitica. — In  congenital  syphilis  characteristic 
lesions,  called  by  Wegner  syphilitic  osteochondritis,  are  frequently 
found  in  the  epiphyses.  The  epiphyses  of  the  newborn  become  enlarged, 
the  enlargements  being  painless.  Sometimes. the  epiphyses  become  sepa- 
rated, and  as  a  result  the  diseased  limb  may  appear  to  be  paralyzed 
(pseudo-paralysis).  The  process  may  also  extend  to  the  neighboring 
joint. 

The  pathological  changes  are  most  marked  in  the  epiphyses,  but  not 
infrequently  they  extend  to  the  shaft  of  the  bone,  differing  in  this  way 
from  rickets.  The  calcified  cartilage  nearest  the  diaphyses  becomes 
friable  and  opaque  and  the  epiphyseal  line  becomes  widened,  irregular, 
and  wavy.  The  adjacent  medullary  cavity  contains  a  grayish  yellow, 
translucent,  granulation  tissue  which  has  undergone  fatty  degeneration. 
Separation  of  the  epiphysis  may  follow  the  development  of  this  tissue. 
Gummata  may  at  the  same  time  develop  in  the  medulla  and  in  the 
inner  layer  of  the  periosteum.  The  interference  with  endochondral 
bone  formation  may  be  indicated  by  shortening  or  lengthening  of 
the  bone. 

Syphilitic  Osteopsathyreosis. — Fragility  of  the  bones  (osteopsathyreo- 
sis)  occurs  in  the  old,  severe  cases  of  syphilis,  as  in  other  chronic  infec- 
tious diseases.  It  is  a  result  of  the  cachexia.  According  to  Charpy, 
there  is  usually  in  these  cases  a  considerable  reduction  of  the  calcium 
fluorid  in  the  bones. 

Diagnosis  of  Syphilis  of  the  Bone. — The  diagnosis  of  syphilitic  dis- 
ease of  bone  is  not  difficult  when  the  disease  is  well  advanced  and  the 
lesions  develop  in  bones  which  are  frequently  affected.  On  the  other 
hand,  the  diagnosis  may  be .  very  difficult  when  there  are  no  other  symp- 
toms of  the  disease.  Deep-lying,  gouty  tophi,  or  tuberculous  abscesses 
attached  to  the  bones  of  the  skull,  forearm,  hands,  and  leg  resemble  very 
closely  periosteal  gummata,  provided  these  have  not  ruptured.  When 
syphilis  produces  an  enlargement  and  expansion  of  a  section  of  a  bone, 
i\  diagnosis  of  fhronic  suppurative  or  tuberculous  osteomyelitis,  or 
of  a  central  oi-  jxridslcal  sarcoma  may  be  made.  Multiple  hyperos- 
toses also  develop  in  the  sclerotizing  form  of  suppurative  osteomye- 
litis. In  I*aget's  disease  (osteitis  deformans)  the  bones  become  ex- 
l)anded  and  deformed.     In  doubtful  cases  in  which  the  clinical  course 


SYPHILIS  477 

gives  no  clue  to  the  nature  of  the  disease,  anti-syphilitie  treatment 
shouhl  be  institnted.  Koentgen-ray  pictures  reveal  nothinu;  charac- 
teristic. 

Treatment. — Besides  the  general  treatment  -which  is  effective  in  the 
early  stages  of  the  disease,  surgical  measures  are  often  required.  Pain- 
ful and  ulcerated  foci  should  be  exposed,  if  necessary,  with  a  chisel, 
and  if  possible  the  gummatous  masses  should  be  removed  with  a  sharp 
spoon;  sequestra  should  be  extracted.  Gunnnatous  abscesses,  if  small, 
should  be  aspirated;  if  large,  they  should  be  incised,  curetted,  and 
treated  by  the  open  method.  * 

Defects  in  the  skull  following  removal  of  sequestra  may  be  closed 
most  quickl}^  by  an  osteoplastic  operation.  Extensive  defects  may  be 
reduced  much  in  size  by  the  gradual  regeneration  of  bone  (Hofmeister), 

(f)  SYPHILIS   OF   THE   JOINTS 

In  the  course  of  syphilis,  one  or  many  joints  may  become  inflamed 
and  the  arthritis  may  pursue  different  clinical  courses.  The  knee  and 
elbow  joints  are  most  frequently  involved. 

In  acquired  syphilis  a  painful  arthritis  with  serous  exudate,  re- 
sembling acute  articular  rheumatism,  may  develop  during  the  eruptive 
stage,  likewise  during  the  relapses.  This  may  subside  after  some  weeks 
if  the  extremities  are  immobilized  and  general  treatment  is  instituted. 
The  restoration  of  finiction  may  be  complete. 

Syphilitic  Hydrops. — A  chronic,  resistant  hydrops,  rarely  ending  in 
suppuration,  may  develop  late  in  syphilis.  It  follows  the  development 
of  gummata  in  the  synovial  membrane  and  the  articular  cartilages. 
The  knee  is  most  commonly  attacked,  and  disease  is  often  symmetrical 
in  its  distribution.  There  is  but  little  interference  with  motion  and  but 
slight  pain.  The  diseased  synovial  membrane  becomes  thickened  and 
covered  with  villous,  even  tumorlike,  masses.  The  articular  cartilage 
becomes  eroded,  the  pathological  changes  being  more  marked  in  the 
center  than  at  the  edges,  and  small  but  deep  cicatricial  defects  form 
which  often  radiate,  like  other  syphilitic  scars  (chondritis  syphilitica, 
Virchow). 

The  diagnosis  is  frequently  difficult,  especially  when  there  are  no 
characteristic  symptoms  or  signs  of  syphilis.  The  involvement  of  many 
joints  and  the  relatively  little  disturbance  of  function  should  suggest 
syphilis.  The  treatment,  in  addition  to  the  general  treatment,  consists 
of  removal  of  the  exudate  and  the  application  of  a  compression  dress- 
ing. Frequently,  after  a  long  time,  the  healing  is  complete.  Not  infre- 
quently the  capsule  is  thickened  and  the  articular  cartilages  are  partly 
destroj^ed.     If  this  is  the  case,  there  will  be  some  limitation  of  motion 


478  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

even  when  healing  is  complete.  A  grating  sensation,  elicited  when  the 
bones  entering  into  the  formation  of  the  joints  are  moved,  is  indicative 
of  the  destruction  of  the  articular  cartilages.  Palpable,  tuniorlike 
growths  in  the  capsule  have  been  successfully  extirpated  (Borchard). 

Arthritis  Following  Rupture  of  an  Intraosteal  or  Periosteal  Gumma. 
— The  arthritis  which  is  secondary  to  the  rupture  of  an  intraosteal  or 
periosteal  focus  into  the  joint  cavity  pursues  the  severest  clinical  course. 
All  of  the  ligaments  and  the  articular  cartilages  may  be  destroyed.  Flail 
joints  or  anchylosis  with  contractures  develop  most  frequently  in  the 
fingers  and  toes,  the  soft  tissues,  bones  and  joints  of  which  may  all  be 
involved   (dactylitis  syphilitica). 

Acute  Gummatous  Arthritis. — Schuchardt  has  shown  that  there  is  aLso 
an  acute  gummatous  arthritis.  Operations  have  been  performed  upon 
cases  in  which  a  diagnosis  of  gonorrheal  artliritis  had  been  made,  and 
miliary  gummata  have  been  demonstrated  in  the  tissues  removed  from 
the  thickened  capsule. 

In  children  with  congenital  syphilis,  not  infrequently  an  exudate 
accompanied  by  but  few  symptoms  develops  rapidly  in  a  number  of 
joints  (most  frequently  in  the  knee  and  elbow).  This  form  of  arthritis 
is  secondary  to  a  syphilitic  osteochondritis  or  to  a  gummatous  inflamma- 
tion of  the  epiphysis  and  synovial  membrane.  Suppuration  in  this  form 
of  arthritis  is  rare.  The  diagnosis  is  difficult,  unless  there  are  other 
lesions  of  syphilis,  such  as  an  interstitial  keratitis.  Under  general  treat- 
ment the  arthritis  subsides  without  any  limitation  of  motion.  Operative 
interference  is  indicated  only  when  fistula  persist  or  the  joint  suppu- 
rates. 

(g)  SYPHILIS   OF   THE   TENDON-SHEATHS  AND   BURSiE 

An  acute  exudative  inflammation  of  tendon-sheaths  and  bursas  may 
develop  during  the  eruptive  stage  of  syphilis.  It  is  comparable  to  the 
serous  arthritis  occurring  during  this  period,  and  like  it  usually  sub- 
sides rapidly.  Frequently  gummata  develop  in  bursee,  especially  in 
those  about  the  knee  joint.  They  develop  slowly  and  without  pain, 
and  may  rupture  through  the  skin  or  through  the  capsule  of  the  joint. 
A  gumma  in  the  skin  or  bone  may  extend  to  a  bursa,  the  latter  becom- 
ing secondarily^  involved.  Syphilis  of  the  tendon-sheaths  is  most  fre- 
quently secondary  to  syphilis  of  bone — for  example,  in  syphilitic 
dactylitis. 

The  diagnosis  of  the  acute  exudative  teudo-vaginitis  and  bursitis 
occurring  in  the  eruptive  stage  is  not  difficult.  The  diagnosis  of  the 
gummatous  form  is  difficult,  especially  if  the  lesion  has  not  perforated 
the  skin,  if  there  are  no  ulcers  or  other  lesions  characteristic  of  the 
disease. 


SYPHILIS  479 

The  treatment  consists  of  exposure  and  removal  of  the  gummatous 
masses,  if  the  lesion  does  not  rapidly  improve  under  general  anti- 
syphilitic  treatment. 

(h)  SYPHILIS   OF   THE    DIFFERENT   VISCERA 

Brief  mention  will  be  inade  of  the  syphilitic  lesions  of  the  brain, 
liver,  and  testicle,  as  these  are  the  most  important  to  the  surgeon. 

Large  gunnnata  developing  within  the  brain  substance  produce  the 
symptoms  of  brain  tumor.  The  same  symptoms  may  be  produced  by 
gummatous  masses  and  exostoses  developing  upon  the  internal  table  of 
the  skull  bones  and  producing  pressure.  Syphilitic  changes  in  the  cere- 
bral arteries  give  rise  to  trajisitory  and  permanent  functional  disturb- 
ances, the  permanent  disturbances  being  always  associated  with  infarc- 
ticm  and  subsequent  softening  of  brain  tissue.  Apoplexy  occurring  in 
early  life  is  fre(juently  due  to  the  arterio-sclerosis  associated  with  syphilis. 

General  interstitial  syphilitic  hepatitis  is  of  less  interest  to  the  sur- 
geon than  the  hepatitis  associated  with  the  development  of  nodular, 
gummatous  nsasses.  Sometimes  it  is  difficult  to  diagnose  between  syphi- 
lis and  carcinoma  of  the  liver.  The  masses  occurring  in  s.yphilis  are  not 
so  hard  as  those  found  in  carcinoma,  and  in  syphilis  notches  develop 
in  the  edge  of  the  liver  as  the  result  of  the  contraction  of  the  inter- 
stitial tissue  lying  between  the  gunnnata. 

Syphilis  of  the  testicle  occurs  in  two  forms,  as  a  diffuse  interstitial 
and  a  gunnnatous  orchitis.  It  is  often  difficult  to  differentiate  the 
gunniiatous  masses,  before  the  skin  has  become  involved  and  the  typical 
ulcers  have  formed,  from  the  hard,  nodular  masses  developing  in  ma- 
lignant growths.  Involvement  of  the  regional  lymph  nodes  speaks  for 
malignancy. 

In  regard  to  the  prognosis  of  syphilis  it  should  be  mentioned  that 
the  majority  of  the  lesions  which  the  surgeon  sees  belong  to  the  late 
forms,  and  these  develop  only  in  severe  cases  or  in  cases  which  have 
been  improperly  treated.  It  should  also  be  remembered  that  there  are 
probably  other  severe  organic  lesions  when  gummata  develop,  even  if 
the  latter  subside  rapidly  under  anti-syphilitic  treatment. 

Treatment. — Preparations  of  mercury  and  potassium  iodid  are  em- 
ployed in  the  treatment  of  syi)hilis.  Good  nutritious  food  and  a  hy- 
gienic mode  of  life  are  very  essential. 

TTie  most  reliable  preparation  of  mercury  is  the  blue  or  gray  oint- 
ment (Unguentum  hydrargyri  einereum).  From  .lij  to  iij  of  the  oint- 
ment should  be  rubbed  in  daily  into  different  parts  of  the  body.  In 
children  from  gr.  15  to  45  should  be  used.  The  entire  surface  of  the 
trunk  and  extremities  should  be  gone  over  in  six  days.     A  full  bath 


480  WOUND   INFECTIONS   OF   DIFFERENT  ORIGINS 

should  be  given  on  the  seventh  day  and  the  ointment  applied  again 
for  six  daj^s,  being  rubbed  into  the  skin  of  the  trunk  and  extremities 
as  before. 

Directions  should  be  given  the  patient  regarding  the  care  of  the 
teeth,  and  a  good  mouth  wash  (water  to  which  are  added  a  few  drops 
of  tincture  of  myrrh  or  acetate  of  aluminum)  should  be  prescribed  in 
order  to  prevent  mercurial  stomatitis  with  the  accompanying  inflam- 
mation and  ulceration  of  the  gums,  loosening  of  the  teeth,  foetor  ex  ore, 
and  salivation.  If  the  stomatitis  becomes  severe,  the  inunctions  should 
be  stopped  and  the  ulcers  cauterized. 

Subcutaneous  injections  and  internal  administration  of  mercurial 
compounds  are  less  reliable  than  the  treatment  by  inunctions.  Although 
there  is  less  danger  of  mercurial  poisoning  and  administration  is  sim- 
pler, when  mercury  is  injected  subcutaneously  or  administered  inter- 
nally recurrences  are  more  frequent.  Mercurial  treatment  should  be 
begun  with  the  development  of  the  eruption,  and  during  the  following 
three  years'  treatm.ent  should  be  continued  at  intervals,  even  if  the  symp- 
toms of  the  disease  do  not  recur  (Fournier  and  Neisser). 

Potassium  iodid  is  usually  employed  in  the  treatment  of  later  syphi- 
litic lesions  (a  saturated  solution  of  potassium  iodid  in  water  being 
employed).  It  is  well  to  begin  with  small  doses  and  gradually  increase 
the  dosage  until  results  are  obtained.  In  adults  it  is  a  good  rule  to 
begin  with  10  drops  three  times  a  day  and  to  increase  the  dose  from 
1  to  2  drops  each  day  until  -symptoms  of  iodism  develop  or  the  lesions 
or  symptoms  improve.  The  drug  should  be  administered  after  meals, 
and  may  be  given  in  milk  or  a  glass  of  water.  In  severe  cases  a  mixed 
treatment  of  mercury  and  potassium  iodid  may  be  employed.  Fre- 
quently potassium  iodid  is  used  for  diagnostic  purposes.  When  used 
for  diagnostic  purposes  in  doubtful  cases  it  should  be  emphasized  that 
the  drug  should  not  be  continued  longer  than  two  weeks  unless  there 
is  improvement.  If  continued  longer  without  any  improvement,  the 
doubtful  lesion — for  example,  a  carcinoma — may  become  inoperable. 

The  symptoms  of  iodism  consist  of  coryza,  conjunctivitis,  headache, 
and  acne.  In  severe  cases  large  furuncles  may  develop.  If  the  symp- 
toms are  severe  the  iodid  preparation  should  be  stopped.  Mild 
symptoms  often  subside  when  the  preparation  is  continued. 

Calomel  is  best  suited  for  internal  administration  in  treating  syphi- 
litic lesions  in  small  children.  Children  a  few  weeks  old  may  be 
given  from  J^ to -J^  ur. ;  cliildi-cii  llii-ee  months  old,-J^gr. ;  if  older,  ^^ 
to  y^  gr.  three  times  daily   (Lesser). 

LiTioiiATiTHK. — O.  liusse.  Uehor  syph.  Entzi'ni(lunf>;on  Ix'i  ((uorj^csf  rcifton  Muskoln. 
Arch.  f.  kliii.  Chir.,  Bd.  69,  V.HY.i,  p.  AHf^.—Borchdrd.  Voher  hu'tisc-he  Geleiikent- 
zundiui^icii.    Deutsche  Zeitschr.  f.  Chir.,  Hd.  (il,  HH)1,  j).  1 10. — v.  Brumann.    Ueber  syph. 


RHINOSCLEROMA  481 

Geschwiilste  in  den  Muskeln.  Berl.  klin.  Wochenschr.,  1889,  p.  120. — Doutrelcpont 
und  Gouven.  Ueber  d.  Nachw.  v.  Spiroch.  pall,  in  tertiiir  syph.  Produkten.  Deuf.sche 
nied.  Wochenschr.,  1906,  p.  908. — v.  Esmarch.  Zur  Diagnose  der  Syphilome.  Chir.- 
Kongr.  Verhandl.,  1895,  II,  p.  298. — Fischer.  Krankheiten  der  Lyriiphgefasse,  Lyniph- 
driisen  und  Blutgefasse.  Deutsche  Chir.,  Stuttgart,  1901. — Hochsinger.  Zur  Kenntnis 
der  hereditilr-syph.  Phalangitis  der  Sauglinge.  Festschrift  fiir  Kaposi,  Wien,  Leij)- 
zig,  1900;— Studien  iiber  die  hereditare  Sy])hilis.  Wien,  1904,  II.  Teil:  Knochener- 
krankungen. — Hofmeister.  Ueber  die  Regeneration  der  Schiidelknochen.  Beitr.  zur 
klin.  Chir.,  Bd.  13,  1895,  p.  453. — Hoffmann.  Nachtrag  zu  der  Arbeit  von  Schaudinn  und 
Hoffmann.  Berlin,  klin.  Wochenschr.,  1905,  p.  726. — Honsell.  Diffuse  sj^jhilitische 
Muskelentzundiuig.  Beitr.  z.  klin.  Chir.,  Bd.  22,  1898,  p.  502.^ — Kaposi.  Pathol,  und 
Therap.  der  Syphilis.  Deutsche  Chirurgie.  Stuttgart,  1891. — Kaufmann.  Pathol. 
Anatomic,  Berlin,  1901. — Klcmm.  Ueber  die  zentrale  gummose  Osteomyelitis  der 
langen  Rohrenknochen.  v.  Volkmann's  Sammlung  klin.  Vortr.,  N.  F.,  No.  273. — Lang. 
Vorlesungen  iiber  Syj^hilis.  Wiesbaden,  1896. — Lesser.  Geschlechtskrankheiten.  Lei})- 
zig,  1901. — Lexer.  Zur  Beurteilung  des  Wertes  der  verschiedenen  Quecksilberpraparate 
in  der  Syph.-Therap.  Arch.  f.  Derm.  u.  Syiih.,  Bd.  21,  1889,  p.  715.— H.  Lorenz.  Die 
Muskelerkrankungen.  Wien,  1898. — Mulzer.  Sammelreferat  iiber  Spirochaetenbe- 
funde  bei  Syphilis.  Archiv  f.  Dermat.  u.  Sjqjh.,  Bd.  79,  1906,  p.  387. — ^4.  Neisser. 
Versuche  zur  Uebertragung  der  Syj^hilis  auf  Aifen.  Deutsche  med.  Wochenschr.,  1906, 
p.  493. — Pielicke.  Die  syph.  Gelenkerkrankungen.  Berl.  klin.  Wochenschr.,  1898, 
p.  78. — Schaudinn  und  E.  Hoffmann.  Vorlaufiger  Bericht  iiber  das  Vorkommen  von 
Spirochaeten  in  syphil.  Krankheitsprodukten  und  bei  Papillomen.  Arbeiten  aus 
dem  kais.  Gesundheitsamte,  Bd.  22,  1905,  p.  2; — Ueber  Spir.  pall,  bei  Sy|3h.  und 
die  Unterschiede,  etc.  Berliner  klin.  Wochenschr.,  1905,  p.  673. — Scliuchardt.  Die 
Krankheiten  der  Knochen  und  Gelenke.  Stuttgart,  1899. — Virchow.  Die  krankhaften 
Geschwiilste,  Bd.  2,  p.  392. — Wieting.  Zur  Sabelscheidenform  der  Labia.  Beitr.  z. 
klin.  Chir.,  Bd.  30,  1901,  p.  615. — Handbuch  der  prakt.  Chirurgie  von  v.  Bergmann, 
V.  Bruns  und  v.  Mikulicz,  I.  Bd.,  v.  Bergmann,  p.  137. 

Literature  Concerning  the  Spiroch^ta  Pallida.^ — Tomasczewski.  Ueber  den 
Nachweis  der  Spirochaete  pallida  bei  tertiarer  Syphilis.  Miinchener  med.  AVochenschr., 
3  Juli,  1906,  p.  1301.  Nachweis  von  Spirochaeten  in  offenen  und  geschlossenen  Gum- 
mata. — Simmonds.  Ueber  den  diagnostischen  Wert  des  Spirochaetennachweises  bei 
Lues  congenita.  Ibid.,  p.  1302.  Wo  Syphilis  congenita  nicht  vorliegt,  sind  (nach 
Untersuchungen  von  26  Fallen)  Spirochaeten  in  den  Organen  von  Sauglingen  und  Foten 
eelbst  bei  vorgeschrittener  Mazeration  nicht  anzutreffen.  Dagegen  fanden  sie  sich  bei 
vier  mazerierten  Foten  syphilitischer  Herkunft  in  der  Haut,  in  Muskeln  und  Knochen 
und  in  samtlichen  Organen,  ferner  sehr  reichlich  ini  Mekonium.  Bei  der  sjq^hilitischen 
Osteochondritis  waren  sie  nur  in  der  Knorpelknochengrenze  und  in  dem  benachbarten 
Pcrioste  erkennbar. 


CHAPTER   XIII 

RHINOSCLEROMA 

RiiiNOSCT.EROMA,  described  first  by  Ilebi-a  and  Kaposi  (1870),  is  a 
chronic,  progressive  disease  which  usuall^y  begins  in  the  mucous  mem- 
brane of  the  nose,  less  frequently  in  that  of  the  pharynx,  larynx,  or 


482  WOUND   INFECTIONS  OF   DIFFERENT   ORIGINS 

palate,  and  then  extends  to  neighboring  parts — the  nose,  tear  passages, 
trachea,  and  lips.  The  disease  is  rare  in  Germany,  very  common  in 
Austria  and  Southwestern  Russia;  occasionally  cases  are  seen  in  Central 
America  and  Italy.  The  disease  develops  most  frequently  in  adults 
of  the  middle  class. 

The  inflammatory  masses, .  which  are  infectious  granulomata,  re- 
semble those  found  in  tuberculosis,  syphilis,  actinomycosis,  leprosy,  and 
glanders.  They  develop  first  in  the  naso-pharynx  and  choanaB,  and 
then  extend  either  to  the  mucous  membranes  of  the  nose,  lips,  cheeks, 
and  gums  or  to  those  of  the  upper  respiratory  passages.  Primary 
as  well  as  secondary  foci  may  develop  in  the  pharynx,  trachea,  and 
larynx. 

The  disease  develops  slowly  and  pursues  a  very  chronic  course.  The 
infiltration  of  the  mucous  membranes  sometimes  appears  in  the  form 
of  nodules;  at  other  times  in  the  form  of  tumors  or  flat,  thickened, 
firm  areas  of  a  cartilaginous  consistency.  The  edges  of  these  infiltrated 
areas  may  be  sharply  defined  or  may  gradually  fuse  with  the  sur- 
rounding healthy  tissue.  The  skin  or  mucous  membrane  covering  such 
lesions  is  reddened,  tense,  and  traversed  by  dilated  veins.  It  is  firmly 
attached  to  the  inflammatory  mass  and  may  be  dry,  fissured,  or  ulcer- 
ated. Extensive  destruction  of  the  infiltrated  areas  does  not  occur; 
on  the  other  hand,  there  is  a  tendency  to  cicatricial  contraction.  Car- 
tilage to  which  the  pathological  process  extends  becomes  fibrillated  or 
hyperplastic. 

Gradually  the  nasal  passages  become  occluded.  These  masses  devel- 
oping in  the  pharynx,  larynx,  and  epiglottis  may  cause  considerable 
interference  with  respiration  and  deglutition.  When  the  skin  of  the 
nose  is  involved  it  becomes  hard  and  bluish  red  in  color,  and  the  nose 
proper  becomes  broad  and  deformed,  the  ala^  nasi  become  separated, 
and  the  hard  inflammatory  masses  extend  to  the  lips. 

All  these  changes,  M^hich  eventually  lead  to  cachexia  or  favor  the 
development  of  some  lesion  in  the  lungs,  develop  within  ten  years. 

Rhinoscleroma  may  be  confused  with  sarcoma,  carcinoma,  and  syphi- 
lis. In  doubtfid  cases  a  microscopic  examination  of  a  piece  of  tissue 
should  be  made. 

In  the  bcgiiniiug  of  tlie  disease  the  lesions  should  be  extirpated.  If 
necessary,  the  nose  should  be  split,  so  that  free  access  may  be  had  to 
the  lesion.  As  a  rule  the  results  following  extirpation  are  not  per- 
manent, as  the  disease  tends  to  T'ecur.  If  comy>lete  removal  is  im- 
possible, snudl  ])ieces  should  be  excised  in  oi'der  to  reestablish  the  nasal 
passages.  11"  Ihe  disease  develops  in  the  lai'ynx,  tracheotomy  may  be 
necessai-y. 

Microscopic  examination  of  llie  lesions  reveals  a  characteristic  con- 


BOTRYOMYCOSIS  483 

nective-tissue  proliferation  wliich  is  most  marked  about  tln>  blood  ves- 
sels. The  cells  of  the  connective  tissue  undergo  a  peculiar  degeneration, 
large,  swollen,  vacuolated  cells  filled  with  bacilli,  cells  which  have  un- 
dergone hyaline  degeneration  and  free  hyaline  masses  being  found  in 
these  lesions.  Large  numbers  of  bacilli  lie  in  the  lymphatic  spaces  or 
in  the  cells. 

The  bacillus  demonstrated  by  von  Frisch  in  1882  is  probably  the 
cause  of  rhinoscleroma.  It  is  a  short,  rounded  rod,  provided  with  a 
mucous  capsule,  frequently  two  bacilli  being  found  within  the  capsule 
(diplo-bacillus).  Notwithstanding  the  fact  that  this  bacillus  is  found 
so  constantly  in  the  lesions  of  the  rhinoscleroma,  it  has  not  been  demon- 
strated that  it  is  the  cause  of  the  disease,  as  animal  experiments  have 
been  negative  and  the  bacillus  resembles  closely  other  bacteria,  such  as 
Friedlander's  pneumo-bacillus,  the  bacillus  of  oza?na,  and  other  encap- 
sulated bacteria  occurring  in  the  nose.  It  is  impossible  to  make  an 
accurate  differentiation  between  the  forms  mentioned. 

Literature. — Babes.     Das   Rhinosklerom.     In   Kolle-Wassermann's    Handb.    tier 
pathog.  Mikroorganisinen,  Bd.  3,  liK)3,  p.  408. 


CHAPTER    XIV 

BOTRYOMYCOSIS 

According  to  Bollinger,  botryomycosis  is  a  disease  characterized 
by  the  development  of  infectious  granulomata  in  the  skin,  grapelike  or 
mulberrylike  groups  of  cocci  being  found  in  the  tissue.  These  can 
hardly  be  differentiated,  even  by  cultural  methods,  from  the  staphy- 
lococcus pyogenes  aureus.  Kiittner  doubts  their  specificity.  The  dis- 
ease occurs  frequently  in  horses;  more  rarely  in  other  domestic  ani- 
mals, and  only  occasionally  in  man. 

The  disease  was  first  demonstrated  in  man  by  Poncet  and  Dor  in 
1897.  Small  nodular  tumors  which,  as  Legrain's  illustrations  show, 
may  sometimes  become  as  large  as  a  fist,  develop  in  the  skin.  The 
surface  of  such  masses,  which  is  often  ulcerated  and  nodular,  bleeds 
easily  and  profusely.  The  nodules  are  soft  in  consistency,  red  in  color, 
and  are  attached  to  the  dermis.  These  masses  grow  slowly,  without 
pain,  and  are  usually  found  upon  the  fingers,  more  rarely  upon  the 
dorsum  of  the  hand,  the  arm,  and  other  parts  of  the  body. 

These  masses  can  be  easily  excised,  as  they  do  not  extend  into  the 
deeper  tissues.  Botryomycosis  may  be  confused  with  angiosarcoma, 
which  is  not  infrequently  pedunculated  and  not  larger  than  a  cherry 


484  WOUND   INFECTIONS   OF   DIFFERENT   ORIGINS 

when  it  develops  upon  the  fingers.     The  microscopic  finding  of  groups 
of  cocci  in  the  tissue  is  of  diagnostic  importance. 

Literature. — Gahinet.  Les  tumeurs  botryomycosiques  chez  le  cheval  et  chez 
rhomme.  Paris,  1902,  Michalon. — Glage.  Botryomykose.  In  Kolle-Wassermann's 
Handbuch  der  pathog.  Mikroorganismen,  Bd.  3,  1903,  p.  795. — KiUtner.  Ueber  telean- 
giekt.  Granulome.  Beitr.  z.  klin.  Chir.,  Bd.  47,  1905,  p.  1. — Legrain.  Archives  de 
Parasitologie,  1898. 


PART   III 
E"ECEOSIS 

The  disturbances  of  nutrition  arising  in  wounds  and  associated  with 
injuries  or  diseases  of  the  blood  vessels,  burns,  frost-bites,  etc.,  are  often 
the  cause  of  anxiety  to  the  surgeon.  If  treatment  does  not  improve 
the  nutrition  of  the  tissue,  death  of  the  same  may  be  unavoidable.  This 
condition  is  known  as  necrosis  or,  because  of  the  charred  appearance 
of  the  tissues,  as  gangrene.  [If  death  is  limited  to  the  soft  tissues,  the 
term  sloughing  or  sphacelation  is  employed,  and  the  dead  tissue  is 
spoken  of  as  a  sphacelus;  gangrene  is  applied  to  the  necrotic  processes 
which  involve  both  soft  tissues  and  bone.] 

Disturbance  of  nutrition  is,  as  a  rule,  synonymous  with  disturbance 
of  circulation  of  the  blood;  for  the  lymph  alone,  even  if  its  circulation 
is  not  interfered  with,  cannot  nourish  large  areas  or  parts  for  any  length 
of  time. 

A  disturbance  of  circulation  follows  the  cutting  and  ligation  of 
large  blood  vessels  during  operations  or  in  accidental-wounds;  the 
laceration  of  large  vascular  trunks  in  subcutaneous  injuries,  and  their 
closure  by  the  pressure  of  blood  poured  out  into  the  tissues ;  the  narrow- 
ing or  dilatation  of  the  vessel  wall,  the  result  of  pathological  changes. 
Whether  the  circulatory  disturbance  subsides  without  permanent  injury 
or  causes  necrosis  or  gangrene  depends  upon  a  number  of  factors: 
(1)  whether  the  circulation  is  completely  stopped  or  merely  interfered 
with;  (2)  whether  the  interference  with  circulation  has  been  sudden 
or  gradual;  (3)  whether  the  cause  is  removed  early  or  late;  and  finally 
(4)  whether  a  collateral  circulation  can  develop  rapidly  enough  to 
supply  the  tissues  with  sufficient  blood.  This  is  possible  when  the 
anastomosing  vessels,  which  must  dilate  easily,  are  present  in  large 
number. 

General  and  Local  Conditions  Favoring  Necrosis. — General  and  local 
conditions  are  also  very  iin})ortant  in  (K'tcnuining  the  fate  of  the  tis- 
sues. A  poor  general  condition  and  cardiac  weakness  may  prevent  the 
recovery  of  the  tissues  even  after  the  interference  with  the  circulation 
has  been  removed  or  a  collateral  circulation  has  been  established.  Ila^ma- 
tomas,  inflammatory  processes,  diseases  of  the  vessels  supplying  the  area, 

485 


486  NECROSIS 

passive  hypergemia  resulting  from  tight  bandages,  or  the  poor  position  of 
the  limb  involved  may  favor  the  development  of  necrosis  or  prevent 
restitutio  ad  integrum. 

Symptoms  of  Beg-inning  Circulatory  Disturbances. — Threatening  cir- 
culatory disturbances  due  to  interference  with  or  cessation  of  the  arte- 
rial flow  are  indicated  by  the  symptoms  of  ischsemia ;  those  due  to  inter- 
ference with  or  cessation  of  venous  return  by  the  symptoms  of  passive 
hyperemia  or  stasis.  The  signs  of  interference  with  circulation  are 
seen  best  in  a  pedunculated  skin  flap,  the  pedicle  of  which  is  too  narrow 
or  too  thin  or  is  constricted  by  the  dressing.  If  the  arterial  circulation 
is  interfered  with  the  flap  becomes  pale  and  cold;  its  edges,  if  there  is 
no  inflammation,  become  dry  and  a  brownish  black  crust  develops.  If 
the  venous  circulation  is  interfered  with  the  flap  swells,  sometimes  the 
entire  flap  becomes  blue,  and  at  other  times  merely  blue  areas  develop. 
The  blood  passes  from  the  small  arteries  into  capillaries  and  veins  filled 
with  blood  which  no  longer  circulates.  The  walls  of  the  capillaries 
and  veins  are  stretched  and  become  permeable  as  a  result  of  the  nutri- 
tional disturbances.  The  blood  is  poured  out  into  the  tissues,  and  the 
flap  becomes  dark  blue  or  black  in  color  when  the  red  blood  corpuscles  are 
destroyed  and  the  blood  pigment  is  set  free.  The  serum  which  raises 
the  epidermis  to  form  the  so-called  gangrenous  blebs  is  also  stained 
by  this  pigment.  Numerous  ecchymoses  which  develop  before  the  in- 
farction of  the  flap  is  complete  are  due  to  tlie  bursting  of  blood  vessels. 
If  dark  blood  is  discharged  from  incisions  made  into  the  flap,  thrombi 
have  not  developed.  When  thrombosis  occurs  the  tissues  die  and  the 
fate  of  the  flap  is  sealed.  [When  flaps  are  sutured  and  there  is  con- 
siderable tension,  it  is  sometimes  advisable  to  make  multiple  small  inci- 
sions into  the  areas  which  are  under  the  most  tension.  The  venous 
blood  escapes  through  these  incisions,  thrombi  do  not  develop,  and  fre- 
quently'' the  flap  may  be  saved.]  When  the  flap  is  destroyed  by  the 
interference  with  venous  circulation,  the  epidermis  gradually  becomes 
separated  from  the  corium  and  is  cast  off  in  shreds  and  strips;  the 
corium,  no  longer  protected,  dries,  forming  a  hard,  black  mass.  Necro- 
sis, beginning  at  the  edge  of  the  flap,  gradually  extends  until  the  entire 
flap  becomes  neci-otic,  uidcss  proper  ti'catmeiit  is  instituted. 

Disturbances  Following  Interference  with  Circulation. — Mild  disturb- 
ances follow  interference  witli,  bnt  not  complete  cessation  of,  either  the 
arterial  or  venous  circulation.  The  resistance  of  the  imperfectly  nour- 
ished tissue  is  reduced  and  chronic  ec/ema  develops,  the  skin  atrophies, 
wounds  no  longer  heal  rapidly,  and  infections  when  once  established 
persist  ami  extend  ra])idly.  Tmpnircd  circulation  is  an  important  etio- 
logical factor  in  the  development  of  varicose  ulcers  and  the  ulcers  devel- 
oping in  arteriosclerosis  and  diabetes. 


NECROSIS  487 

Other  Causes  of  Necrosis. — Disturbance  of  circulation  is  the  most 
important,  but  not  the  only  cause  of  necrosis.  Tissues  may  become 
necrotic  as  the  result  of  crushing  injuries  and  the  action  of  chemical 
and  thermal  agents.  The  cell  protoplasm,  as  the  result  of  the  action  of 
injurious  agents,  is  no  longer  able  to  assimilate  foodstutts,  even  when 
enough  vessels  remain  intact  to  supply  the  necessary  material. 

Necrosis  and  Necrobiosis. — When  death  of  tissues  quickly  follows  the 
infliction  of  an  injury,  it  is  called  necrosis;  when  death  follows  slowly, 
and  is  preceded  by  degenerative  changes  in  the  cells,  it  is  called  necro- 
b  iosis. 

Necrosis  and  Gangrene. — Clinically,  dry  is  differentiated  from  moist 
gangrene.  Dry  gdiigrene  (necrosis,  mummification)  is  the  result  of  the 
occlusion  of  the  artery  supplying  the  area  involved,  provided  a  suf- 
ficient collateral  circulation  is  not  established  rapidly.  The  tissues, 
previous  to  their  death,  are  drained  of  their  fluid.s,  or  the  fluids  are 
lost  by  evaporation  at  points  where  the  epithelium  is  destroyed,  and 
the  deeper  tissues  become  dry,  shrunken,  hard,  and  black.  Moist  gan- 
grene (necrosis  humida)  occui-s  only  when  the  tissues  before  their  death 
have  been  oedematous,  and  in  those  conditions  in  which  infections,  espe- 
cially with  putrefactive  bacteria,  favor  liquefaction  of  the  tissues,  a 
process  which  is  observed  in  different  degrees  in  every  severe  suppura- 
tive and  putrefactive  infection.  The  term  gangrene  is  at  the  present 
time  applied  by  many  authors  to  the  moist,  foul-smelling  forms  of  ne- 
crosis only. 

Formation  of  Granulation  Tissue  and  the  Line  of  Demarcation. — 
Granulation  tissue  develops  about  the  edges  of  the  dead  tissue  as  the 
result  of  a  reactive  inflammation.  It  is  the  same  process  that  occurs 
in  every  open  wound,  about  foreign  bodies  and  inflammatory  foci.  The 
dead  tissue  is  gradually  separated  from  the  living  by  granulation  tissue 
and  the  ferments  which  are  liberated  by  the  leucoc^ytes  wandering  into 
this  zone.  The  line  of  denuircation  gradually  becomes  more  distinct 
and  the  necrotic  tissue  becomes  separated  from  the  slightly  elevated 
wall  of  granulation  tissue  by  a  groove  filled  with  fluid  resembling  pus. 

The  necrotic  tissue  is  cast  off  when  enough  healthy  granulation  tis- 
sue develops  to  separate  the  living  from  the  dead.  The  time  required 
for  the  separation  of  necrotic  tissue  depends  upon  the  character  of  the 
tissue  and  the  size  of  the  necrotic  mass;  for  example,  from  one  to  two 
weeks  are  required  for  the  separation  of  necrotic  skin,  from  two  to 
three  mouths  for  the  separation  of  necrotic  bone. 


488  NECROSIS 


CHAPTER   I 

NECROSIS    DUE    TO     TRAUMA:    (1)     THE    DIRECT    RESULT    OF    TRAUMA, 
(2)    FOLLOWING   INJURIES    OF    THE   BLOOD   VESSELS 

Pieces  of  tissue  completely  separated  from  neighborino;  structures 
become  necrotic  unless  conditions  exist  or  are  provided  which  favor 
healing.  Conditions,  however,  are  rarely  favorable,  as  the  tissues  are 
crushed,  blood  is  extravasated,  ha-matomas  form,  and  bacterial  infec- 
tions may  develop.  Healing,  as  a  rule,  occurs  only  when  tissues  are 
transplanted,  as  in  these  cases  conditions  are  provided  which  favor 
rapid  healing. 

Necrosis  Produced  by  Blunt  Force. — Necrosis  frequently  follows-  the 
application  of  blunt  force.  The  tissues  are  more  apt  to  become  necro- 
tic when  acted  upon  by  blunt  force,  as  the  vessels  are  crushed,  the  in- 
tima  is  lacerated,  and  thrombi  develop,  closing  the  vessels.  Machine 
injuries,  in  which  the  tissues  are  lacerated  and  the  larger  blood  vessels 
are  torn,  may  cause  in  this  way  necrosis  of  an  entire  extremity.  Skin 
which  is  crushed  and  separated  from  the  subcutaneous  fat  and  fascia 
by  blunt  force  frequently  becomes  necrotic. 

Necrosis  Following  Occlusion  of  Blood  Vessels. — Viscera,  an  entire 
extremity  or  ])arts  of  it  may  become  necrotic  as  the  result  of  an  injury, 
rupture,  occlusion  (by  malignant  growths)  or  ligation  (for  cure  of 
aneurysm)  of  the  principal  artery,  providing  a  sufficient  collateral 
circulation  is  not  established  quickly  enough  to  provide  for  the  nour- 
ishment of  the  tissues.  General  weakness  of  the  patient,  pathological 
changes  in  the  vessel  wall,  and  the  pressure  of  extravasated  blood  may 
prevent  the  establishment  of  a  collateral  circulation. 

The  viscera  undergo  necrosis  most  rapidly  when  the  vessels  supply- 
ing them  (arteries  or  all  the  veins)  are  injured  or  ligated.  It  is  well 
known  that  necrosis  of  the  testicle  may  follow  injury  of  the  arteries 
in  the  cord  in  the  repair  of  an  inguinal  hernia,  or  in  operating  upon  a 
varicocele.  Necrosis  of  the  kidney,  spleen,  or  intestines  follows  injury 
or  ligation  of  the  arteries  supplying  them.  [These  arteries  are  ter- 
minal, and  a  collateral  circulation  is  not  established  even  under  favor- 
able conditions.]  Ligation  of  the  intci-nal  carotid  artery  is  followed 
in  about  forty  per  cent  of  the  cases  by  focal  degeneration  or  necrosis 
of  the  brain. 

Results  of  Ligation  of  Some  of  the  Principal  Arteries  of  the  Extremi- 
ties.— The  results  following  ligation  of  tlie  princii)al  arteries  of  the 
extremities  differ.  Of  course  the  stati.stics  pre^pared  from  operations 
perrornied    in    preantiseplie,   times   are   not   as   good    as   those   prepared 


NECROSIS   DUE  TO  TRAUMA  489 

later,  when  antisepsis  and  asepsis  rendered  wound-in feetions,  which 
often  defeated  the  purpose  of  the  operator,  much  less  frequent. 

Gangrene  follows  in  from  one  to  two  per  cent  of  the  cases  of  ligation 
of  the  common  femoral  vein  (Frankel,  Franz),  in  about  twenty  per 
cent  of  the  cases  of  ligation  of  the  femoral  artery  (Raabe),  and  in 
from  fifty  to  sixty  per  cent  of  the  cases  of  simultaneous  division  of 
both  the  femoral  artery  and  vein  (von  Bergmann,  Ziegler).  Gangrene 
occurs  in  fifty  per  cent  of  the  cases  of  ligation  of  the  popliteal  artery, 
and  always  follows  simultaneous  ligation  of  both  artery  and  vein  (von 
Bergmann,  Janssen). 

The  results  following  ligation  of  the  arteries  of  the  upper  extremity 
are  more  favorable.  Gangrene  follows  in  only  about  two  per  cent  of 
the  cases  of  ligation  of  the  subclavian  artery  (von  Bergmann).  Even 
simultaneous  ligation  of  both  the  artery  and  vein  is  not  so  dangerous, 
as  the  conditions  are  favorable  for  the  establishment  of  a  collateral 
circulation.  Ligation  of  the  axillary  artery  is  followed  by  gangrene 
in  six  per  cent  of  the  cases,  of  the  brachial  artery  in  eighteen  per  cent 
(cf.  Iloepfner). 

Factors  Interfering  with  or  Preventing  the  Development  of  a  Col- 
lateral Circulation. — It  may  be  seen  from  the  above  that  in  many  cases 
gangrene  does  not  follow  occlusion  of  the  principal  arteries  and  veins, 
even  the  simultaneous  occlusion  of  both.  Gangrene,  however,  invariably 
follows  simultaneous  ligation  of  both  the  popliteal  artery  and  vein.  If 
gangrene  occurs,  when  the  anatomic  conditions  are  favorable  for  the 
establishment  of  a  collateral  circulation,  there  is,  as  a  rule,  some  patho- 
logical change  which  interferes  with  the  nutrition  of  the  tissue.  The 
following  are  the  most  frequent  conditions  which  prevent  the  estab- 
lishment of  a  collateral  circulation:  (1)  general  and  cardiac  weakness; 
(2)  loss  of  blood  following  operation  or  accident;  (3)  alterations  in  the 
composition  of  the  blood,  such  as  occur  in  ana?mia,  diabetes,  infectious 
diseasas;  (4)  arteriosclerosis,  dilatation  of  the  veins,  thrombosis,  iuHam- 
niation,  interference  with  the  circulation  by  exudation  of  blood  benenth 
unyielding  fascia,  by  tight  bandages,  or  by  the  dependent  position  dT  the 
extremity. 

Symptoms  of  Gangrene. — The  symptoms  which  indicate  the  begin- 
ning of  gangrene  are  those  of  ischa-mia  or  passive  hypera^nia.  The  part 
of  the  extremity  below  the  point  of  occlusion  becomes  white,  cold,  and 
puls(>less  or  edematous,  mottled  and  dark  blue  in  color,  and  covered 
with  large  vesicles  containing  a  blood-stained  serum.  The  changes  are 
most  marked  in  the  distal  parts  of  the  extremity.  In  the  beginning 
there  are  parsesthesia  and  dull  pain ;  finally  complete  sensory  and  motor 
paralyses  develop  unless  the  condition  is  relieved.  An  ischapmic  muscle 
loses  its  electrical  excitability  after  five  hours.  Even  after  complete  loss 
32 


490 


NECROSIS 


of  sensation  a  severe,  aggravating  pain  which  is  referred  to  the  nerves 
distal  to  the  line  of  demarcation  continues.  Motor  paralyses  develop 
when  the  bellies  of  the  muscles  have  degenerated.  Usually  the  first 
symptoms  of  a  dry  or  moist  gangrene  develop,  when  the  principal 
vessels  are  involved,  as  early  as  the  second  day  upon  the  fingers  and 
toes.  Unless  a  collateral  circulation  is  established  in  a  few  days  the 
process  extends,  involving  the  entire  part  below  the  point  of  occlusion. 
In  favorable  cases  the  gangrene  remains  limited 
to  the  tips  of  the  fingers  or  toes  or  to  isolated 
areas   in    the   sldn    of   the   hand    or   foot,    which 


X 


Fig.  206. — Necrosis^  (Dky  Gangrene)  of  the  Arm  following  Rupture  of  a  Diseased 
Axillary  Artery  while  Attempting  to  Reduce  an  Old  Dislocation  of  the  Shoul- 
der. Patient  was  a  woman  sixty-nine  years  of  age.  Appearance  of  the  arm  four  weeks 
after  ligation  of  the  artery. 


heal  after  the  necrotic  tissue  is  cast  off.  The  death  of  the  tissue  is 
most  rapid  when  infected.  Not  infrequently,  phlegmonous  inflamma- 
tion and  lymphangitis  develop  as  the  result  of  infection  of  the  granu- 
lation tissue  of  the  demarcation  zone. 

Symptoms  of  Gangrene  of  the  Viscera. — The  symptoms  of  necrosis 
of  the  viscera  differ,  alterations  of,  interference  with  or  a  complete 
cessation  of  their  specific  functions  being  the  most  pronounced.  The 
testicle  is  superficial  and  presents  quite  definite  symptoms  when  it  be- 
comes necrotic.  The  scrotum  becomes  inflamed  and  o^dematous  and  a 
seroha'inoi-rhagic  exudate  is  poured  out  into  the  tunica  vaginalis. 

Treatment. — An  attempt  should  be  made  in  the  treatment  of  necro- 
sis, the  direct  or  indirect  result  of  trauma,  to  prevent  the  introduction 
and  development  of  putrefactive  bacteria.  The  surrounding  area  should 
be  cleansed  and  sterilized,  and  a  dry,  aseptic  dressing  should  then  be 
applied.  Only  in  dry,  superficial  gangrene  of  the  skin  can  a  moist 
dressing  be  applied  without  danger.  In  these  cases  a  moist  dressing 
of  acetate  of  aluminum,  or  boric  acid,  without  rubber  protective,  has- 
tens the  formation  of  granulation  tissue  and  the  separation  of  the 
necrotic  tissue.     Such  a  dressing  should  be  changed  daily  or  oftener. 

Necrotic  viscera,  such  as  the  spleen,   intestine,   kidney,   and  testicle, 


NECROSIS  THE   RESULT   OF   PRESSURE  491 

should  be  removed  as  soon  as  possible  in  order  to  prevent  the  inflam- 
mation of  the  membrane  (peritoneum)  and  tissues  (loose  connective 
tissue  of  the  scrotum)   surrounding  them. 

In  gangrene  of  the  extremities  the  operation  should  be  postponed, 
unless  there  are  indications  for  innnediate  interference,  until  the  line 
of  demarcation  becomes  well  established  and  distinct.  This  prevents  the 
unnecessary  removal  of  tissue  and  the  po&sibility  of  making  the  ampu- 
tation through  tissues  which  will  later  become  necrotic.  If  lymphan- 
gitis, phlegmonous  inflammation,  or  fever  accompanied  by  putrefac- 
tion develop,  amputation  should  no  longer  be  postponed.  Frequently 
it  is  the  only  procedure  which  will  prevent  the  development  of  a  general 
putrefactive  infection. 

In  the  after-treatment  following  ligation  of  the  principal  artery  of 
the  extremity,  an  attempt  should  be  made  to  favor  the  development 
of  a  collateral  circulation  and  to  prevent  necrosis. 

Bandages  should  be  applied  loosely,  the  extremity  should  be  sup- 
ported upon  soft  cushions  or  pillows,  hypera^mic  areas  in  the  skin 
should  be  punctured,  and  soft  tissues  infiltrated  with  large  amounts  of 
blood  should  be  incised  down  to  the  vessel.  If  gangrene  from  venous 
stasis,  the  result  of  the  ligation  of  a  vein  or  of  a  vein  and  an  artery, 
threatens,  the  extremity  should  be  elevated  or  vertically  suspended  at 
once  in  order  to  favor  the  return  flow  of  the  venous  blood. 


CHAPTER    II 

NECROSIS    THE    RESULT    OP    PRESSURE,     CONSTRICTION,     INVAGINATION,     AND 

TORSION 

In  this  form  of  necrosis  the  circulation  is  interfered  with  or  com- 
pletely stopped  by  compression  of  the  vessels. 

Decubitus. — Pressure  necrosis  (decubitus)  occurs  most  frequently  in 
feeble,  emaciated  patients  who  are  compelled  to  lie  in  a  recumbent  or 
any  one  particular  position  for  a  long  time.  It  develops  most  fre- 
quently over  bony  prominences,  such  as  the  sacrum,  the  spines  of  the 
vertebrae,  the  spine  of  the  scapula,  and  the  os  ealcis. 

A  similar  form  of  necrosis  which  occurs  most  frequently  upon  the 
lateral  margin  of  the  foot,  the  base  of  the  fifth  metatarsal  bone,  over 
the  heel,  the  malleoli,  the  tendo  Achillis,  the  crest  of  the  tibia,  the 
patella,  the  trochanter  major,  the  spines  of  the  ilium  and  the  chin  may 
follow  the  use  of  imperfectly  padded  or  improperly  applied  splints. 
More  rarely,  skin  surfaces  which  are  in  contact,  such  as  the  folds  of 


492  NECROSIS 

the  groin,  the  scrotum,  and  the  inner  surface  of  the  tliigh,  undergo 
pressure  necrosis. 

The  pain,  which  is  present  in  the  beginning,  gradually  subsides  un- 
less maintained  by  inflammation.  The  blue  and  discolored  area  exposed 
to  pressure  becomes  ana'sthetic  and  dries  to  form  a  hard,  black  crust, 
which  is  gradually  separated  from  the  surrounding  structures  by  granu- 
lation tissue.  The  ulcer  which  forms  when  the  crust  is  removed  resists 
treatment,  for  usually  the  general  condition  of  the  patient  is  poor  and, 
besides,  the  ulcer  is  subjected  to  continuous  pressure.  Such  ulcers 
developing  over  the  sacrum  frequently  become  infected,  as  they  are 
contaminated  by  urine  and  faeces.  A  painful  suppurative  or  putre- 
factive inflaiimiation  which  undermines  the  skin  then  develops;  the 
fascia  becomes  gangrenous  and  the  surface  of  the  bone  is  exposed. 

Erysipelas,  phlegmons,  and  severe  general  infections,  associated  with 
metastases  which  develop  from  thrombi  originating  in  the  inflamed  veins 
of  the  necrotic  area,  are  fre(|uently  terminal  events  in  these  cases. 

The  first  indication  in  the  treatment  of  pressure  necrosis  is  to  re- 
move the  cause.  This  is  much  more  easily  accomplished  when  the  pres- 
sure is  produced  by  a  tight  bandage  than  when  it  follows  long  confine- 
ment in  one  position.  An  attempt  should  be  made  to  prevent  bedsores 
from  developing  by  providing  soft,  smooth  bed  clothing,  or  by  using  water 
cushions  or  rubber  rings.  The  tissues  surrounding  the  area  exposed  to 
pressure  should  be  rubbed  dailj^  with  alcohol,  dried,  and  dressed  aseptic- 
ally.  Moist  dressings  macerate  the  skin,  transfer  infection,  and  favor 
the  development  of  a  pustular  eczema.  A  dressing  of  ten  per  cent  zinc- 
vaseline  ointment  lessens  the  ])urni]ig  sensation  and  favors  the  formation 
of  granulation  tissue  and  cicatrization.  The  prevention  of  pressure 
necrosis  is  one  of  the  most  important  duties  of  a  nurse.  When  a 
patient  has  been  operated  upon  and  his  position  cannot  be  easily 
changed,  especial  care  should  be  paid  to  keeping  the  bed  clothing  and 
the  nightgown  smooth,  and  to  supplying  clean  linen.  Air  or  water 
cushions  are  api)reciated  very  much  by  weak,  emaciated  patients. 

The  beginner  should  learn  to  protect  al]  bojiy  prominences  and  pro- 
jecting tendons  when  a])plyiiig  a  plaster-of-Paris  dressing. 

Necrosis  due  to  constriction  may  develop  when  one  of  the  turns  of 
a  bandage  is  too  tight  or  Avhen  an  Esmarch  constrictor,  applied  to  pro- 
duce an  artificial  ischa-mia,  is  allowed  to  remain  too  long.  IschaMiiic 
necrosis  may  develop  when  a  constrictor  is  allowed  to  remain  in  position 
for  two  and  a  half  hours.  Tt  is  easily  understood  how  much  greater 
the  dangers  of  necrosis  are  when  the  constrictor  is  allowed  to  remain 
much  longer.  Plaster-of-Paris  dressings  may  cause  necrosis,  especially 
when  applied  to  an  extremity  the  circulation  of  which  is  already  inter- 
fered with  by  extravasations  of  blood  or  pathological  changes  in  the 


NECROSIS  THE   RESULT  OF   INVAGINATION  AND  TORSION      493 

vessel  wall  (arteriosclerosis).  Necrosis  is  preceded,  as  a  rule,  in  these 
cases  by  marked  passive  hypera'iiiia,  and  the  tissues  are  sacrificed  to  the 
pressure  of  the  bandages.  In  all  dressings,  especially  when  plaster-of- 
Paris  casts  are  applied,  the,  fingers  and  toes  should  remain  free  so  that 
after  the  bandages  are  applied  they  may  be  inspected  on  the  following 
day.  If  they  are  pale  or  blue,  swollen,  anaesthetic,  or  cannot  be  moved, 
the  dressing  should  be  removed  immediately  and  reapplied  with  great 
care,  or  the  limb  should  be  immobilized  in  some  other  dressing  until 
the  swelling  subsides  and  the  cast  can  then  be  reapplied.  A  mistake 
frequently  made  is  to  apply  tight  bandages  over  infected  wounds  and 
phlegmons.  The  inflammatory  swelling  may  lead  to  circulatory  disturb- 
ances and  necrosis  in  a  shoi't  time. 

Gangrene  of  the  fingers  often  develops  in  patients  who  have  applied 
a  constrictor  about  the  upper  arm,  thinking  that  it  would  prevent  the 
extension  of  the  red  streaks  occurring  in  lymphangitis.  Constriction  of 
the  penis,  such  as  is  frequently  seen  when  a  rubber  constrictor  or  ring 
is  applied  to  produce  an  erection,  is  as  dangerous  as  paraphimosis,  in 
which  a  retracted,  narrow  foreskin  causes  the  circulatory  disturbance. 
As  a  rule,  there  develops  within  twenty-four  hours  a  marked  venous 
stasis  which  may  end  in  necrosis  unless  relieved.  The  necrosis  may 
extend  deeply,  involving  all  the  tissues  distal  to  the  constricting  band. 

Gangrene  of  the  arm  of  the  newborn  may  develop  after  a  difficult 
labor  in  which  a  prolapsed  arm  has  been  pressed  upon  for  a  long  time 
by  the  head  incarcerated  in  the  pelvic  inlet  (Fritz  INIiiller). 

Gangrene  Following  Strangulation,  Invagination,  and  Volvulus. — 
Strangulation  of  intestinal  loops  in  a  hernial  ring  may  lead  to  marked 
circulatory  disturbances  in  a  short  time.  The  intestinal  wall  is  then  no 
longer  able  to  resist  the  bacteria  upon  its  mucous  membrane  and  be- 
comes gangrenous.  The  changes  are  most  marked  and  develop  earliest 
at  the  point  of  constriction. 

Faecal  phlegmons  developing  from  the  hernial  sac,  or  putrid  peri- 
tonitis are  the  results  of  strangulation,  unless  it  is  relieved  by  early 
operation  with  resection  of  the  gangrenous  loops  and  end-to-end  or 
lateral  anastomosis  of  the  resected  ends. 

Torsion  or  volvulus,  by  which  is  understood  a  rotation  of  the  gut 
upon  its  mesenteric  axis,  interferes  with  the  passage  of  intestinal  con- 
tents, and,  after  a  while,  with  circulation,  ending  in  gangrene.  Vol- 
vulus occurs  most  frequently  in  the  sigmoid  flexure,  caecum,  and  small 
intestines.  Volvulus  of  the  stomach  occurs  occasionally.  In  a  similar 
way  a  piece  of  omentum  or  a  pedunculated  tumor  may  be  deprived  of 
nutrition  by  torsion.  This  occurs  most  frequently  in  ovarian  tumors 
and  pedunculated  fibromyomas  of  the  uterus.  Even  the  uterus,  when 
it  contains  fibroids  of  unequal  size,  may  undergo  torsion;  likewise  the 


494  NECROSIS 

testicle,  when  it  has  an  abnormally  long  niesorchium,  the  homologue 
of  the  mesentery,  which  permits  of  a  wide  range  of  motion,  may  nndergo 
torsion  and  become  gangrenous. 

The  symptoms,  when  the  torsion  is  sudden,  are  acute  and  severe. 
The  symptoms  of  volvulus  of  the  intestine  are  those  of  ileus,  consisting 
of  pain,  vomiting,  meteorism,  and  obstipation.  An  operation  should  be 
performed  as  soon  as  the  diagnosis  of  volvulus  is  made;  in  doubtful 
cases  an  exploratory  laparotomy  is  advisable.  If  the  circulatory  dis- 
turbances are  not  so  far  advanced  as  to  cause  gangrene,  the  loops  may 
be  returned  to  their  original  position. 

If  the  integrity  of  the  intestinal  wall  has  suffered,  the  gangrenous 
loop  should  be  resected  and  an  end-to-end  or  a  lateral  anastomosis 
should  be  made  or  an  artificial  anus  established,  depending  upon  the 
local  and  general  conditions. 


CHAPTER    III 

NECROSIS    THE    RESULT    OP    THERMAL    AND    CHEMICAL    CAUSES 

High  and  low  temperatures  (145°  F.  and  —30°  F.)  may  destroy 
even  resistant  tissues  in  a  short  time ;  lesser  degrees  of  heat  and  cold 
destroy  tissues  after  acting  for  a  longer  time.  If  gangrene  develops  some 
time  after  the  action  of  heat  or  cold,  it  is  due  to  the  thrombus  forma- 
tion induced  by  them  (vide  "  Burns  and  Frost-bites,"  Part  IV,  Chap- 
ter III). 

The  harmful  action  of  Roentgen  and  radium  rays  should  be  men- 
tioned here.  Chronic  ulcers  follow  the  necrosis  of  areas  of  skin  which 
have  been  exposed  too  long  or  improperly  to  these  rays.  The  granu- 
lation tissue  develops  slowly,  and  a  long  time  is  required  for  healing. 
These  ulcers  are  especially  chronic  and  resistant  to  treatment.  This  is 
probably  due  to  the  changes  in  the  vessel  wall  (endarteritis  obliterans) 
induced  by  the  rays  (vide  Miihsam). 

There  are  a  number  of  different  chemical  agents  which  may  cause 
necrosis. 

All  agents  used  as  caustics,  especially  acids  and  alkalies,  destroy  tis- 
sues l)y  extracting  water  from  or  forming  chemical  union  with  the 
cytoplasm  or  interfering  with  circulation.  The  chemical  agents  used  in 
sterilization  may  be  dangerous  even  when  diluted,  especially  when  the 
protecting  epithelium  is  absent  or  rapidly  destroyed,  when  there  is 
inflammatory  hypera'iiiia  with  threatened  stasis,  or  when  the  resistance 
of  the  tissues  is  reduced  by  general  anemia  or  weakness  of  the  patient. 


NECROSIS  THE   RESULT    OF   THERMAL   AND   CHEMICAL   CAUSES     495 

Carbolic  Acid  Necrosis. — The  use  of  carbolic  acid  in  Lister's  dress- 
ing soon  taught  that  this  agent  could  cause  severe  local  disturbances 
in  the  wound  and  skin  which  might  end  in  gangrene,  basides  the  gen- 
eral intoxication.  Carbolic  acid  is  still  retained  as  the  favorite  germi- 
cidal agent  hy  the  laity,  in  spite  of  the  fact  that  it  has  been  removed 
from  the  armamentarium  of  the  surgeon.  Not  infrequently  a  wound  of 
the  finger  or  toe  is  dressed  by  lay  people  with  a  moist  carbolic  acid 
compress,  with  the  result  that  carbolic  acid  gangrene,  which  may  even 
follow  the  application  of  a  one  per  cent  carbolic  acid  solution  for 
twenty-four  hours,  develops. 

Levai,  Ilonsell,  and  Rosenberger  have  shown  that  this  action  is  not 
specific  for  carbolic  acid.  The  gangrene  is  due  to  disturbances  in  circu- 
lation, and  is  similar  to  that  produced  by  other  dilute  chemical  agents. 
After  the  carbolic  acid  has  deprived  the  epithelial  cells  and  the  super- 
ficial tissues  of  their  water,  it  passes  between  the  shrunken  cells  to  the 
])lood  vessels,  which,  after  a  transitory  contraction,  become  dilated.  As 
a  result  of  the  dilatation,  the  blood  stream  becomes  slowed,  a  transudate 
is  poured  out  into  the  subcutaneous  tissues,  and  conse<(uently  the  nutri- 
tion of  the  tissues  is  interfered  wdth,  and,  as  there  is  no  absorption, 
the  ])oison  accumulates  in  the  tissues.  Thrombosis  of  the  vessels  is  not, 
as  Frankenburger  believes,  the  cause,  but  the  result  of  the  necrosis. 
According  to  Rosenberger,  coagulation  of  the  blood  is  even  delayed  by 
carbolic  acid. 

Gangrene  Following  Lysol  and  Alcoholic  Compresses. — Compresses  of 
lysol  and  alcohol  may  have  a  similar  action,  but  the  gangrene  does  not 
develop  so  rapidly,  and  never  extends  so  deeply  as  that  produced  by 
carbolic  acid.  The  latter,  if  applied  for  an  acute  inflammatory  process, 
such  as  a  felon  or  a  carbuncle,  especially  if  evaporation  is  prevented  by 
rubber  tissue,  may  transform  the  entire  hyperaemic  area  into  a  hard, 
black  crust. 

Destructive  Action  of  Physiological  Secretions  and  Excretions. — Even 
normal  physiological  secretions  and  excretions  have  a  caustic  action 
when  they  come  in  contact  with  exposed,  unprotected,  epithelial  sur- 
faces. This  digestive  action  is  occasionally  seen  in  imperfectly  per- 
formed gastrostomies  from  which  gastric  juice  is  discharged.  An  ec- 
zema then  develops  about  the  gastrostomy  opening  and  a  chronic 
phagedenic  ulcer  results  from  the  digestion  of  the  surrounding  tissues 
after  the  protecting  epithelium  is  destroyed.  The  digestive  action  of  the 
gastric  juice  probably  plays  a  part  in  the  formation  of  ulcer  of  the 
stomach.  The  mucous  membrane  becomes  necrotic  as  a  result  of  tliroin- 
bosis  of  the  blood  vessels  or  injury,  and  the  necrotic  area  is  then  digested 
by  the  gastric  juice. 

The  discharge  of  pancreatic  juice  into  the  fatty  tissue  of  the  omen- 


496  NECROSIS 

turn,  mesentery,  and  posterior  abdominal  wall  following  inflammation 
or  injury  of  the  pancreas  is  followed  by  necrosis  of  small  circumscribed 
areas.  After  the  fatty  tissue  is  decomposed  into  glycerin  and  fatty 
acids,  calcium  salts  unite  with  the  latter  to  form  the  yellowish  white 
nodules,  the  size  of  a  pea,  which  are  so  characteristic  of  fat  necrosis. 

Urine,  when  it  infiltrates  the  tissues,  causes  extensive  necrosis.  If 
there  is  an  accompanying  bacterial  infection,  a  putrid  phlegmon  usu- 
ally develops  (p.  300). 

Faeces  contain  bacteria  and  toxins,  and  severe  infections  with  gan- 
grene follow  the  escape  of  intestinal  contents  into  the  tissues. 

Even  in  a  bacterial  inflammation  the  toxins  are  principally  responsi- 
ble for  the  death  of  the  tissues.  The  injured  or  dead  tissues  in  rapidly 
extending  inflammations  become  necrotic  or  gangrenous.  When  the 
clinical  course  is  prolonged  the  tissues  are  liquefied  by  the  action  of  the 
leucocytes  (pus  formation).  Interference  with  the  circulation  in  these 
cases  also  contributes  to  gangrene  of  tissues,  as  all  the  vessels  in  the 
inflamed  area  finally  become  closed  by  thrombi. 


CHAPTER    IV 

GANGRENE   DUE   TO   EMBOLISM    AND   THROMBOSIS 

Embolism  and  thrombosis  are  closely  related  as  the  causes  of  gan- 
grene (vide  Part  V,  Chapter  IV). 

Causes  of  Embolism  and  Thrombosis — Vessels  Most  Frequently  In- 
volved.— Emboli  most  frequently  lodge  at  the  point  of  division  of  an 
artery ;  for  example,  in  the  popliteal  artery  or  in  the  aorta  at  the  point 
of  bifurcation  or  where  the  lumen  of  the  artery  is  suddenly  decreased 
by  tlie  giving  oft"  of  a  large  branch.  The  emboli  are  carried  from 
some  part  of  the  arterial  system  nearer  the  heart  or  from  the  left 
heart;  only  in  exceptional  cases  in  which  the  foramen  ovale  remains 
patent,  from  the  right  heart.  Sclerosis  and  syphilis  of  the  arteries, 
j)iirulciit  arteritis  in  local  and  general  infections,  aneurysms  and 
contusions  of  the  vessel  wall  are  the  most  common  causes  of  throm- 
l)osis.  Particles  of  a  thrombus  or  an  entii'e  thrombus  may  be  loosened 
and  cai-j'ied  in  the  circulating  blood  to  lodge  in  some  artery  more  dis- 
tant from  the  henrt.  Endocarditis,  the  result  of  some  infectious  disease, 
of  wliich  typhoid  fever,  smallpox,  scarlet  fever,  and  general  pyogenic 
infections  are  the  most  inq)ortant,  is  the  fre(iuent  source  of  emboli. 

Of  flu;  arteries  of  the  systemic  circulation,  those  of  the  extremities 
;iii(l   intestines  are  the  ones  most  fi-equently  closed  by  emboli  with  sub- 


GANGRENE   DUE   TO   EMBOLISM   AND  THROMBOSIS  497 

sequent  necrosis  or  gangrene.  Embolism  of  the  intestinal  arteries,  the 
symptoms  of  which  are  those  of  ileus,  sometimes  ends  fatally  from 
haemorrhage  due  to  infarction  of  the  intestinal  wall,  sometimes  from 
gangrene  of  the  intestinal  wall  with  perforation  and  subsequent  peri- 
tonitis. Frequently  embolism  of  these  vessels  is  mistaken  for  internal 
strangulation  or  volvulus. 

Symptoms. — The  symptoms  of  embolism  or  thrombosis  of  the  arteries 
of  the  extremities,  those  of  the  leg  (popliteal,  femoral,  iliac)  being  much 
more  frequently  involved  than  those  of  the  arm,  are  very  distinct  and 
definite.  The  symptoms  begin  suddenly  with  severe  and  persisting  pain 
in  the  extremity  involved,  the  skin  of  which  becomes  cold  and  pale  or 
mottled.  Motor  and  sensory  paralysis  develops  within  a  few  hours,  just 
as  in  the  gangrene  which  follows  ligation  of  the  principal  artery  of  an 
extremity.  The  severest  pain,  however,  is  referred  to  the  part  which  is 
becoming  gangrenous.  No  pulse  can  be  felt  in  the  artery  below  the 
point  of  occlusion.  The  point  at  which  the  embolus  is  lodged  is  hard 
and  painful  upon  pressure. 

Clinical  Course  of  Embolism. — The  clinical  course  of  embolism  dif- 
fers from  now  on.  If  the  occlusion  is  complete  the  fate  of  the  limb  de- 
pends upon  whether  or  not  a  collateral  circulation  is  established.  Fre- 
quently cardiac  weakness,  general  arterial  disease,  arterial  thrombosis 
extending  from  the  point  of  lodgment  of  the  embolus  toward  the  heart, 
severe  inflammation  of  the  vessel  wall  caused  by  bacteria  in  the  embolus 
prevent  the  rapid  development  of  a  collateral  circulation  which  is  suf- 
ficient to  maintain  the  nutrition  of  the  part  involved.  In  favorable 
cases  an  oedema  which  persists  for  some  time  develops,  the  skin  becomes 
reddened,  as  the  smaller  veins  and  capillaries  become  distended,  and 
the  symptoms  of  paralysis  subside. 

If  a  collateral  circulation  is  not  established,  as  frequently  happens 
after  traumatism  of  arteries,  the  distal  parts  of  the  extremity  become 
gangrenous  and  the  gangrene  extends  in  the  next  few  days  to  the  level 
at  which  the  line  of  demarcation  develops. 

If  the  occlusion  is  not  complete  from  the  beginning,  but  gradually 
becomes  so  as  blood  coagulum  is  deposited  upon  an  embolus,  the  clinical 
picture  differs.  The  vis  a  tergo  is  diminished  and  the  small  amount  of 
l)lood  reaching  the  part  stagnates.  The  skin  becomes  bluish  red  in  color, 
gangrenous  blebs  form,  and  ecchymoses  and  cedema  develop. 

Mummification  is  limited,  as  a  rule,  to  the  fingers  and  toes.  The 
soft  tissues  around  the  demarcation  zone  often  become  gangrenous,  not- 
withstanding that  they  are  protected  by  aseptic  dressings.  Putrid 
thrombophlebitis  and  general  infections  may  develop  from  such  an  area. 

In  rare  cases,  gangrene  of  both  extremities  may  be  of  embolic  origin. 
The  embolus  in  these  cases  Iodides  at  the  bifurcation  of  the  aorta  into 


498  NECROSIS 

the  iliac  vessels,  and  is  increased  by  later  deposits  of  fibrin,  eventually 
closing  both  branches,  or  the  embolus  divides  and  pieces  are  carried 
into  more  distal  arteries,  such  as  the  popliteal.  Goedecke  describes  a 
ease  of  embolic  gangrene  of  the  four  extremities,  eventually  terminating 
fatally,  which  followed  suppurative  peritonitis. 

Prognosis. — The  prognosis  of  embolic  gangrene  of  the  extremities 
is  always  very  grave.  It  is  largely  dependent  upon  the  disea.ses  or 
arterial  changes  which  result  in  the  formation  of  the  embolus,  and  the 
fact  that  other  emboli  may  be  set  loose  and  cause  necrosis  of  important 
viscera. 

Arterial  Thrombosis.^ — Arterial  thrombosis  is  the  cause  of  gangrene 
of  the  extremities,  when  clots  arising  within  an  aneurysm  developing 
at  the  site  of  an  injury  of  the  intima,  at  the  point  of  pressure  of  a 
tumor,  or  resulting  from  acute  or  chronic  inflammation  of  the  arterial 
wall,  occlude  one  of  the  larger  arteries.  Acute  arteritis  follows  most 
frequently  typhoid  fever,  more  rarely  general  pyogenic  infections  and 
other  infectious  diseases,  and  is  caused  by  the  deposition  of  bacteria 
in  the  vasa  vasorum.  Cardiac  weakness  is  also  an  important  accessory 
etiological  factor  in  the  formation  of  arterial  thrombi  (marantic 
thrombi). 

Symptoms. — The  symptoms  of  gangrene  following  thrombosis  of  an 
artery  are  not  so  acute  and  severe  as  those  following  embolism.  The 
symptoms  develop  slowly  and  the  conditions  are  favorable  for  the  de- 
velopment of  a  collateral  circulation  unless  the  anastomosing  branches 
are  also  diseased.  There  is  always  more  blood  in  the  extremity  than  is 
the  case  M^hen  the  ischa?mia  is  due  to  embolism. 

The  dangers  depend  for  the  most  part  upon  the  disease  which  results 
in  the  formation  of  a  thrombus. 

Clinically  it  is  impossible,  anatomically  very  difficult,  to  determine 
whether  the  artery  has  been  closed  by  a  thrombus  or  partially  occluded 
by  an  embolus  upon  which  has  been  deposited  masses  of  fibrin  result- 
ing in  secondary  thrombosis  and  complete  occlusion.  Kelatively  rapid 
development  of  gangrene  si)eaks  against  chronic  disease  of  the  blood 
vessels. 

Treatment. — The  same  rules  should  be  observed  in  the  treatment  of 
gangrene  due  to  embolism  and  thrombosis  as  have  been  given  for  the 
treatment  of  gangrene  following  ligation  of  larger  arteries.  Amputa- 
tion should  be  postponed  until  the  line  of  demarcation  is  well  estal)- 
lislied  and  distinct,  uidess  there  are  indications  for  immediate  ampu- 
tation, such  as  pnti-efaetive  changes,  or  unless  the  disease  to  which  the 
embolism  oi-  tln-ombosis  is  secondary  ])ursu(!S  a  severe  course.  If  an 
ami)utalion  has  been  made  through  necrotic  tissue,  reampntation  may 
be  performed  when  the  line  of  demarcation  becomes  distinct. 


NECROSIS  RESULTLNG  FROM  CHRONIC  DISEASE  OF  VESSEL  WALL    499 

CHAPTER    V 

NECROSIS   RESULTING   FROM    CHRONIC    DISEASE   OP    THE   VESSEL    WALL 

Dilatation  or  narrowing  of  arteries  and  veins  (the  results  of  patho- 
logical processes)  may  lead  to  marked  circulatory  disturbances  which 
may  end  in  gangrene. 

Aneurysms  are  only  rarely  the  cause  of  gangrene,  unless  associated 
with  thrombosis  or  embolism  of  some  of  the  larger  arteries,  even  when 
the  impaired  nutrition  of  the  tissues  below  the  aneurysm  is  indicated  by 
nervous  changes  and  the  tendency  to  eczema.  IMummification  of  the 
fingers  is  a  frecjuent  accompaniment  of  a  racemose  hemangioma  of  the 
forearm. 

The  most  frequent  cause  of  gangrene  is  the  narrowing  of  a  number 
of  the  branches  of  an  artery  or  of  one  of  the  larger  arterial  trunks  by 
a  proliferation  of  the  intima,  which,  by  favoring  thrombus  formation, 
may  lead  to  complete  occlusion  of  the  vessel  or  vessels.  These  changes 
are  most  common  in  arteriosclerosis  and  syphilitic  endarteritis.  The 
arterial  changes  occurring  in  diabetic  gangrene  are  closely  related  to 
the  former. 

Arterio-  or  angiosclerotic  gangrene  is  called  senile  gangrene  when  it 
occurs  in  the  aged;  presenile,  when  it  occurs  in  the  young  or  middle- 
aged. 

This  form  of  gangrene  occurs  most  frequently  in  men.  The  feet  are 
most  frequently  affected,  but  it  also  develops  in  the  hand  and  attacks 
the  toes  and  fingers.  In  the  beginning  it  attacks  one  foot  or  hand ; 
frequently  the  disease  develops  in  the  other  after  a  time.  It  develops 
gradually  after  prodromata,  consisting  of  sensations  of  cold,  numbness, 
neuralgic  and  rheumatic  pains  aggravated  by  walking  when  the  lower 
extremities  are  involved,  and  of  cyanosis  of  the  feet  and  hands,  have 
persisted  for  a  long  time.  The  frequent  occurrence  of  this  form  of 
gangrene  in  the  lower  extremity  is  explained  by  the  unfavorable  circu- 
latory conditions  and  the  exposure  of  this  part  to  mechanical  insults. 

Often  the  beginning  of  gangrene  is  indicated  by  the  spontaneous 
development  of  a  bluish  black  area  at  the  tip  of  a  toe  or  finger ;  often 
it  follows  some  external  violence,  such  as  an  insignificant  injury,  the 
trimming  of  a  corn,  the  pressure  of  a  boot  or  shoe,  freezing,  and  not 
infrequently  the  application  of  a  carbolic  acid  compress.  Sometimes  a 
dry,  at  other  times  a  moist,  gangrene  which  is  frequently  accompanied 
by  lymphangitis  and  phlegmonous  inflammations  develops.  The  process 
may  remain  limited  to  the  toe  or  finger  primarily  involved  or  extend 
upward,  involving  the  larger  parts  of  the  extremities.     All  the  fingers 


500  NECROSIS 

or  toes  of  an  extremity  may  become  gangrenous.    When  the  mnmmified 
parts  drop  off  the  stumps  heal. 

(a)  Angiosclerotic  and  Senile  Gangrene. — Cardiac  weakness  is  often 
associated  with  pathological  changes  in  the  walls  of  the  arteries  as  an 
etiological  factor  in  senile  gangrene.  The  veins  are  also  frequently  dis- 
eased, and  for  this  reason  the  term  angiosclerosis  is  employed.  The  ex- 
tent of  the  calcification  of  the  arteries  and  the  involvement  of  even  the 
finer  branches  may  be  seen  in  Roentgen-ray  pictures  when  the  process  is 
far  advanced  (Fig.  207).    Cardiac  weakness  and  arteriosclerosis  are  the 


Fig.  207. — Roentgen-ray  Picture  showing  Arteries  of  the  Forearm  and  Hand  in 
Advanced  Arteriosclerosis.  Male  patient  fifty-nine  years  of  age.  Dry  gangrene  of 
the  terminal  phalanx  of  the  index  finger. 

usual  predisposing  causes;  the  determining  causes  may  be  very  different. 
As  a  result  of  weakness  or  injury,  a  thrombus  develops  in  the  capillaries 
or  smaller  vessels  or  an  occluding  thrombus  develops  upon  an  atheroma- 
tous ulcer  in  one  of  the  larger  arteries.  The  collateral  circulation  is  not 
sufficient  to  provide  for  the  nutrition  of  the  part,  as  the  vessels  enter- 
ing into  it  are  already  diseased  or  are  occluded  by  the  growth  of  the 
thrombus. 

In  the  presenile  gangrene  occurring  in  young  people,  cardiac  weak- 
ness is  also  usually  an  etiological  factor.  Obliteration  of  the  lumina 
of  the  vessels  is  due  partly  to  the  proliferation  of  the  intima  (endar- 
teritis obliterans)  and  partly  to  the  development  of  thrombi.  Thrombi 
may  prevent  in  a  number  of  ways  the  establishment  of  a  collateral 
circulation:  (1)  A  thrombus  may  completely  occlude  a  small  diseased 
artery;  (2)  a  thrombus  may  develop,  in  limited  or  extensive  arterio- 
sclei'osis,  at  a  point  at  which  one  of  the  large  lateral  branches  is  given 
off'  and  occlude  it;  (3)  multiple  thrombi  may  develop  or  a  thrombus 
may  spread  toward  the  heart,  occluding  even  the  aorta  and  all  the 
branches  given  off'  from  it  (Weisz,  Zoege,  von  Manteuffel,  Bunge,  Man- 
tanowitseh).  Excessive  use  of  tobacco  and  alcohol  and  exposure  to 
cold  (Zoege,  von  Manteuffel)  are  impoi'lant  etiological  factors  in  the  de- 
velopment of  ai'teriosclerosis.  Iludnitzki  has  sliown  that  endarteritis, 
with  proliferation,  follows  i-epeated   fi-eezing  of  the  extremities  of  ani- 


NECROSIS  RESULTING  FROM  CHRONIC  DISEASE  OF  VESSEL  WALL     501 

mals.  According  to  Wulff  and  Iligier,  presenile  gangrene  may  be  due 
to  abnormal  vasoconstriction  similar  to  that  occurring  in  Raynaud's 
disease. 

Diagnosis. — The  diagnosis  of  angiosclerotic  gangrene  should  not  be 
based  upon  the  degeneration  of  arteries  alone.  If  it  is  not  probable 
that  the  gangrene  is  due  to  traumatism,  then  thrombosis  or  embolism, 
diabetes,  syphilis,  and  nervous  diseases  should  be  excluded. 

Treatment. — In  the  treatment  an  attempt  should  be  made  to  prevent 
infection  of  the  gangrenous  area  by  using  dry  aseptic  dressings.  If 
inflannnation  develops,  the  epidermis  raised  by  the  secretion  should  be 
removed  in  order  to  prevent  its  extension.  Moist  compresses  of  alu- 
minum acetate,  without  rubber  protective,  hasten  the  separation  of  the 
gangrenous  tissue.  Alcohol  and  carbolic  acid  compresses  should  never 
be  used,  as  these  agents  alone  may  cause  gangrene. 

Phlegmons  require  incision.  If  a  phlegmon  does  not  subside  after 
incision  and  if  the  condition  of  the  patient  becomes  rapidly  worse,  im- 
mediate amputation  is  indicated.  Great  care  should  be  exercised  in 
the  application  of  a  constrictor  for  artificial  ischa-mia.  It  should  be 
applied  where  the  artery  is  well  protected  by  muscles,  and  in  all  cases 
it  is  well  to  apply  a  heavy  towel  or  a  bandage  about  the  extremity  before 
applying  the  constrictor,  thus  taking  extra  precaution  against  injury. 

If  the  arteriosclerosis  is  advanced,  it  is  well  to  perform  the  ampu- 
tation without  a  constrictor,  using  digital  compression  of  the  artery  or 
catching  the  vessels  with  artery  forceps  as  they  are  exposed  or  cut. 
The  amputation  should  be  performed  rapidly  and,  if  used,  the  con- 
strictor should  not  be  allowed  to  remain  any  longer  than  is  absolutely 
necessary.  If  allowed  to  remain  any  length  of  time  it  may  cause  an 
extension  of  the  gangrene.  Skin  flaps  and  bone  flaps  should  not  be 
made  because  of  the  dangers  of  necrosis.  If  the  patient  has  myocarditis 
or  nephritis,  a  general  anaesthetic  should  not  be  used ;  local  or  spinal 
anaesthesia  should  be  employed  instead. 

(b)  Diabetic  gangrene  is  closely  related  to  angiosclerotic  gangrene. 
["  It  is  mainly  due  to  the  abnormal  condition  of  the  blood  in  diabetes, 
thereby  reducing  the  power  of  the  tissues  to  resist  bacterial  invasion,  but 
is  also,  in  a  measure,  the  result  of  sclerosing  endarteritis  and  peripheral 
neuritis." — Rose  and  Carless,  "  INlanual  of  Surgery,"  p.  113.]  The  re- 
sistance of  the  tissues  in  diabetes  is  so  reduced  that  pyogenic  and 
putrefactive  infections  extend  rapidly  and  cause  rapid  and  extensive 
destruction  of  tissue,  even  when  the  vessels  are  not  diseased.  Infec- 
tions extend  much  more  rapidly  and  are  nnich  more  destructive  when, 
in  addition  to  the  lowered  resistance  of  the  tissues,  there  are  circulatory 
and  nutritional  disturbances,  the  result  of  pathological  changes  in  the 
walls  of  the  arteries. 


502 


NECROSIS 


Lowered  Resistance  of  the  Tissues. — The  following  example  of  the 
rapid  progress  and  fatal  termination  of  an  infection,  which  ordinarily 
could  easily  have  been  controlled,  may  be  cited.  A  student  twenty 
years  of  age,  suffering  from  diabetes,  was  shot  in  the  back  while  hunt- 
ing. An  acute,  rapidly  extending  gangrene  of  the  skin  and  muscles, 
wiiich  soon  terminated  fatally,  rapidly  developed,  although  there  were 
no  pathological  changes  in  the  arteries  supplying  the  part. 

Infections  in  Experimoitul  Diabetes. — The  animal  experiments  made 
by  Bujwid,  Groszmann,  and  Hildebrandt,  concerning  the  relation  be- 
tween diabetes  and  infections  are  interesting  and  instructive.  They 
have  shown  that  micro-organisms  multiply  much  more  rapidly  in  and 
are  more  pathogenic  for  diabetic  than  non-diabetic  animals.  A  sub- 
cutaneous injection  of  a  streptococcic  culture  into  animals  suffering 
from  experimental  diabetes  produces  a  severe  inflammation  associated 
with  gangrene  of  the  tissues  and  ulcer  formation,  while  the  same  amount 
injected  into  a  normal  animal  is  absorbed  and  produces  no  symptoms. 

The  facts  that  inflamed  tissues  in  diabetic  subjects  rapidly  become 

gangrenous,  that  suppuration  is  rare,  and  that  when  it  does  occur  but 

little  pus  is  formed  indicate  that  the  resistance  of  the  tissues  to  bac- 

V  terial    infections    is    greatly    reduced 

{vide  Pyogenic  Infections), 

Clinical  Course  of  Diabetic  Gan- 
grene.— Clinically  the  relation  between 
gangrene  and  inflammation  is  much 
more  striking  in  diabetic  than  any 
other  variety  of  gangrene.  Diabetic 
gangrene  may  begin,  as  an  arterio- 
sclerotic gangrene  usually  does,  in  the 
skin  of  one  of  the  toes.  Prodromata, 
Avhich  have  already  been  described  in 
discussing  senile  gangrene,  may  have 
been  present  for  some  time.  Inflam- 
mation then  develops  in  the  gangre- 
nous area,  and,  as  a  result,  uncompli- 
cated dry  gangrene  or  mummification 
is  rare  in  this  disease.  The  reverse 
may  happen ;  that  is,  inflammation  de- 
velops first,  often  at  some  point  of 
pressure,  in  a  fissured  callous  (upon 
the  heel,  sole  of  the  foot,  or  in  the 
])alm  of  llic  hand)  or  after  excision  of  a  corn,  and  gangrene  develops 
secondary  to  the  inflammation. 

As   a  result,   diabetic  necrosis  or  gangrene   is   rarely  limited,   and 


Fig.  208. — Diabktic  Ganorf.nk. 


NECROSIS  RESULTING  FROM  CHRONIC  DISEASE  OF  VESSEL  WALL    503 

separation  of  the  dead  tissues  with  spontaneous  healing-  rarely  ever 
occurs.  Diabetic  spreads  nmeh  more  rapidly  than  senile  gangrene,  as 
infection  is  frequent  and  it  may  destroy  a  large  part  of  the  foot  or  leg. 

Complications. — The  dangers  of  diabetic  gangrene  are  those  asso- 
ciated with  the  rapid  extension  of  the  gangrene  and  the  development  of 
phlegmons  which  may  cause  general  infections.  Complications,  which 
may  develop  at  any  time  in  the  clinical  course  of  diabetes,  add  to  the 
gravity  of  the  prognosis.  The  most  important  of  these  will  be  briefly 
mentioned:  (1)  Attacks  of  acute  cardiac  weakness,  caused  as  a  rule  by 
arteriosclerosis,  which,  after  a  short  febrile  reaction,  may  end  in  fatal 
collapse.  (2)  Diabetic  coma,  beginning  with  prodromata  consisting  of 
nausea,  restlessness,  and  headache,  followed  shortly  by  severe  nervous 
disturbances  (stupor,  delirium,  and  unconsciousness)  and  ending  fatally 
in  a  few  hours  or  days.  [Fatal  coma  may  develop  when  general  anaes- 
thesia is  administered  to  diabetic  patients.  In  this  connection  it  is  in- 
teresting to  note  that  acetone  and  beta-oxybutyric  acid  are  found  in 
the  urine  of  a  majority  of  patients  to  whom  chloroform  is  administered. 
Ether  seems  to  have  less  effect  upon  metabolic  processes  than  chloro- 
form; beta-oxybutyric  acid  is  not  found  so  frequently  after  this  anaes- 
thetic. Becker,  especially,  has  drawn  attention  to  the  dangers  of  ad- 
ministering chloroform  to  diabetics.]  Psychical  irritation  may  follow 
operations  upon  diabetic  subjects  even  when  performed  under  local 
anaesthesia. 

Treatment:  Prophylactic  and  Surgical. — In  the  treatment  of  dia- 
betic gangrene  an  attempt  should  be  made  to  check  the  elimination  of 
sugar  by  prescribing  a  suitable  diet  and  by  internal  medication.  The 
diet  suggested  by  von  Noorden  is  very  valuable  in  these  cases.  The  indi- 
cations for  surgical  interference  depend  entirely  npon  the  course  of  the 
gangrene  and  the  general  condition  of  the  patient.  The  extremity 
should  always  be  immobilized  in  well-fitting  and  padded  splints  and 
elevated  in  order  to  combat  the  lymphangitis  {vide  General  Rules  for 
Treatment  of  Infections,  p.  190)  and  improve  the  circulation. 

Dry  gangrene,  which  is  rare  in  diabetes,  should  be  treated  according 
to  the  rule  already  given  for  the  treatment  of  senile  gangrene.  INIoist 
compresses,  however,  should  never  be  used  in  diabetic  gangrene,  as  they 
favor  the  development  of  putrefactive  processes  (Konig).  If  putre- 
faction occurs,  hydrogen  peroxid  should  be  used. 

Incision  of  a  gangrenous  phlegmon  is  sufficient  if  more  radical 
measures  are  not  indicated  by  the  general  condition  of  the  patient;  for 
as  the  glyeoha>mia  subsides  under  anti-diabetic  treatment,  aiid  as  the 
general  condition  of  the  patient  improves,  the  inflammation  subsides 
and  the  gangrene  becomes  limited.  Dry  dressings  favor  mummification, 
moist  dressings,  with  the  exception  of  those  of  hydrogen  peroxid,   do 


504  NECROSIS 

harm.  The  epidermis  raised  by  collections  of  pus  should  always  be 
removed.  If,  however,  the  phlegmonous  inflammation  spreads  and  the 
gangrene  extends  in  spite  of  incision,  if  a  high  fever  persists,  if  the 
amount  of  sugar  is  not  decreased,  if  the  general  condition  of  the  pa- 
tient becomes  worse,  or  if  from  the  beginning  there  is  great  weakness, 
symptoms  of  cardiac  insufficiency,  or  prodromata  of  diabetic  coma, 
amputation  is  indicated.  Recovery  occurs  in  about  sixty  per  cent  of 
the  cases  (Groszmann).  The  point  at  which  the  amputation  should  be 
performed  depends  altogether  upon  the  extent  of  the  inflammation  and 
the  disease  of  the  arterial  w^all.  If  the  plilegmon  has  extended  to  the 
leg,  or  if  the  popliteal  artery  is  occluded  and  transformed  into  a  hard 
cord,  a  thigh  amputation  should  be  performed.  If  the  gangrene  is  of 
the  dry  variety  and  limited,  a  Pirogoff  or  Chopart's  amputation  or  an 
exarticulation  of  the  gangrenous  toes  may  be  sufficient. 

If  gangrene  develops  in  the  flaps  after  an  amputation  and  extends, 
reamputation  at  a  higher  level  must  be  performed. 

The  operation  should  be  as  simple  as  possible  (circular  amputation 
without  formation  of  flaps  is  best)  and  should  be  performed  under  the 
strictest  aseptic  precautions.  Touching  of  the  w^ound  surfaces  with  the 
Angers  should  be  particularly  avoided.  The  Esmarch  constrictor,  if  the 
arteries  are  sclerotic,  should  be  allowed  to  remain  in  position  as  short 
a  time  as  possible.  Many  surgeons  use  merely  digital  compression  of 
the  principal  arteries  when  performing  amputaticnis  under  these  con- 
ditions. On  the  other  hand,  it  should  be  mentioned  that  the  loss  of 
even  a  small  amount  of  blood  may  prove  dangerous  when  the  arteries 
are  diseased  and  the  heart  is  weak.  If  there  is  lymphangitis,  the  wound 
should  not  be  sutured,  but  should  be  tamponed  with  iodoform  gauze. 

Dangers  of  General  Avcestliesia  in  Diabetic  Patients. — A  general 
ancesthetic  should  not  be  administered  to  a  diabetic  patient  unless  it  is 
absolutely  necessary,  and  should  not  be  continued  any  longer  than  is 
required  for  the  performance  of  the  operation.  Frequently  a  general 
ana«thetic  (especially  chloroform)  increases  the  acetonuria  and  glyco- 
suria. Not  infrequently  diabetic  coma  follows  general  amrsthesia.  Ac- 
cording to  Becker,  chloroform  and  ether,  especially  the  former,  cause 
in  healthy  men  a  slight  and  transient  acetonuria  (Kausch). 

Even  local  anaesthesia  by  infiltration  is  not  without  danger  in  these 
cases.  The  infiltrated  tissues  may  become  gangrenous,  and  besides  the 
operation  cannot  be  performed  so  expeditiously  and  there  is  greater 
danger  of  infection.  Frcvjuently  the  patients  become  nervous  and 
greatly  excited,  and  this  n)ay  lead  to  fatal  syncope  or  diabetic  coma 
(as  has  happened  in  von  Bergmann's  clinic).  Spinal  anaesthesia  is 
well  suited  for  these  cases,  as  it  is  borne  well  and  permits  of  rapid, 
uninterrupted  ami)utations  of  the  lower  extremities.     [Nitrous  oxid  gas 


NECROSIS  RESULTING  FROM  CHRONIC  DISEASE  OF  VESSEL  WALL     505 

is  the  anaesthetic  of  choice  in  these  cases.]  Subsidence  of  the  fever  and 
decrease  in  the  amount  of  sugar  after  the  amputation  are  always  favor- 
able signs.     Treatment  is  practically  useless  after  coma  has  developed. 

Acid  Intoxication. — It  has  been  suggested  that  diabetic  coma  is 
caused  by  an  intoxication  with  acids,  especially  beta-oxybutyric  acid, 
the  result  of  abnormal  metabolic  processes  (Stadelmann).  AVhen  this 
intoxication  occurs,  the  blood  is  no  longer  able  to  form  a  chemical 
union  with  the  carbon  dioxid  in  the  tissues  and  to  remove  it.  Acting 
upon  this  theory,  attempts  have  been  made  for  a  number  of  years  to 
prevent  the  accumulation  of  these  abnormal  acids  in  the  blood  by 
administering  alkalies,  especially  sodium  bicarbonate  by  mouth  or  in 
a  three  to  five  per  cent  solution  intravenously.  Kausch  has  recently 
recommended  the  administration  of  sodium  bicarbonate  before  opera- 
tions upon  diabetic  patients,  or  when  coma  is  threatened  or  has  devel- 
oped. He  administers  large  doses,  as  much  as  150  gm.  in  twenty-four 
hours. 

(c)  Syphilitic  gangrene  of  the  extremities  is  the  result  of  syphilitic 
changes  in  the  larger  arteries  and  their  branches,  with  secondary  throm- 
bosis. Syphilitic  endarteritis  occurs  both  in  congenital  and  acquired 
syphilis. 

It  is  difficult  to  estimate  the  frequency  of  this  form  of  gangrene,  and 
it  is  frequently  confused  with  gangrene  of  the  extremities  due  to  other 
causes,  especially  with  the  presenile  form  of  angiosclerotic  gangrene. 

It  occurs  more  frequently  in  men  than  in  women  and  attacks  the 
young  and  middle-aged.  Clinically  it  does  not  differ  from  the  arterio- 
sclerotic gangrene  occurring  in  young  people.  The  prodromata  are  the 
same  and  of  as  long  duration.  The  gangrene,  which  is  as  a  rule  limited 
in  extent,  develops  upon  the  fingers  and  toes,  frequently  in  a  number 
of  different  areas,  and  may  occasionally  be  symmetrical  (Elsenberg). 
It  may  be  associated  w^ith  phlegmonous  inflammation.  After  the  necro- 
tic tissue  is  cast  off,  chronic  ulcers  which  resist  treatment  form.  The 
large  arteries  of  the  extremities  are  transformed  into  hard,  pulseless 
cords  in  which  may  be  demonstrated  circumscribed  nodular  thickenings. 

According  to  Haga,  who  with  Scriba  has  emphasized  the  frequent 
occurrence  of  syphilitic  disease  of  the  larger  arteries  in  the  Japanese, 
besides  the  obliterating  growth  of  the  intima,  foci  of  granulation  tissue 
develop  in  the  walls  of  the  artery  which  correspond  to  gunnnata.  These 
changes  have  also  been  described  by  Baumgarten  in  the  cerebral  arteries. 

Syphilitic  disease  of  the  arteries  should  always  be  thought  of  when 
gangrene  of  the  fingers  and  toes  develops  in  young  people  (luuler  thirty- 
five  years)  slowly,  after  years  of  circulatory  disturbances.  This  is  espe- 
cially so  when  there  are  indications  of  a  congenital  or  an  acquired 
syphilis.  A  definite  diagnosis  can  be  made  only  when  the  circulatory 
33 


506  NECROSIS 

disturbances  and  the  other  symptoms  subside  under  anti-syphilitic 
treatment,  or  a  microscopic  examination  of  the  arteries  of  the  ampu- 
tated limb  can  be  made. 

The  same  rules  concerning  dressings  and  indications  for  operation 
as  have  been  given  for  angiosclerotic  gangrene  should  be  followed.  Of 
course,  anti-syphilitic  treatment  with  mercury  preparations  and  potas- 
sium iodid  should  be  tried  before  more  radical  measures  are  instituted. 

(d)  Varicose  Veins. — Circulatory  disturbances,  the  result  of  dilata- 
tion of  the  veins,  are  of  very  frequent  occurrence  in  the  leg  {vide 
Phlebectases). 

Predisposing  and  Determining  Causes  of  Varicose  Veins. — Impair- 
ment of  the  venous  circulation  alone,  due  to  insufficiency  of  the  valves 
of  the  dilated  veins,  is  not  sufficient  to  cause  necrosis  of  the  skin.  In 
the  changes  associated  with  varicose  veins,  however,  the  regenerating 
power  of  the  tissues,  especially  those  covering  the  anterior  surface  of 
the  tibia  and  the  malleoli,  are  so  reduced  that  any  lesion,  such  as  a  con- 
tusion, a  scratch,  an  abrasion,  or  an  infection,  does  not  heal  rapidly, 
but  tends  to  spread  and  form  an  ulcer.  Impairment  of  venous  circu- 
lation is  a  predisposing  cause  in  the  development  of  varicose  ulcers; 
there  are  a  number  of  determining  causes,  such  as  abrasions,  contu- 
sions of  the  cutaneous  and  subcutaneous  tissues,  infiltration  of  the  tis- 
sues with  blood  (the  result  of  the  bursting  of  a  varix),  infection  of  the 
skin,  secondary  to  supjjuration  of  a  thrombus,  and  hyperff'mia  asso- 
ciated with  a  furuncle  by  which  the  venous  circulation  is  still  more 
impaired.  Wherever  any  of  these  lesions  occur,  there  may  be  a  super- 
ficial and  limited  necrosis  of  the  skin,  which  extends,  resulting  in  the 
development  of  the  typical  varicose  ulcers. 

The  development  and  extension  of  these  ulcers,  the  difficulty  in 
securing  permanent  repair,  and  the  frequent  recurrence  after  healing 
are  due  to  causes  other  than  the  impairment  of  circulation  following 
dilatation  of  the  veins.  Some  of  these  causes  will  be  mentioned:  (1) 
Impairment  of  circulation  from  excessive  walking  or  too  long  standing, 
which  are  required  in  so  many  callings  and  professions.  The  small 
veins,  already  filled  with  blood,  rupture  and  small  haemorrhages  occur 
in  the  floor  of  the  ulcer  or  into  the  delicate  scar  which  is  already  form- 
ing, resulting  in  the  necrosis  of  tissue  and  extension  of  the  ulcer.  (2) 
All  varieties  of  bacteria  are  deposited  upon  the  surface  of  the  ulcer. 
Infection  occurs,  the  ulcer  becomes  larger  and  deeper,  and  gangrene, 
which  causes  a  rapid  cxlension  of  the  necrotic  process,  may  develop. 
The  necrosis  is  due  not  only  to  the  ])acterial  toxins,  but  also  to  the  inflam- 
matory hypera-mia  of  the  surrounding  tissue,  which,  as  the  circulation 
of  the  tissues  is  already  iiiq)aii-('d,  leads  to  rapid  stasis  in  and  throm- 
bosis of  the  inflamed  veins.     Acute  progressive  inllanniiations,  such  as 


NECROSIS  RESULTING  FROM  CHRONIC  DISEASE  OF  VESSEL  \\ALL     507 


erysipelas,  lymphangitis,  and  thrombophlebitis,  may  result  in  occlusion 
of  the  veins  by  thrombi  and  interfere  with  the  return  flow  of  blood. 
(3)  In  old  ulcers  large  amounts  of  cicatricial  tissue  form,  which  may 
even  extend  into  the  tissues  surrounding  the  ulcer. 

The  thin  skin  becomes  adherent  to  the  underlying  structures  and 
the  edges  of  the  ulcer  become  indurated  and  fixed.  If  the  ulcer  extends 
completely  around  the  leg,  the  contraction  of  the  cicatricial  tissue  may 
interfere  still  more  with  the  vencms  circulation,  causing  a  mai-ked 
chronic  cedema,  with  elephantiasis  of  the  skin  of  the  foot.  [Occasion- 
ally the  interference  with  venous  circulation  is  so  great  that  moist  gan- 
grene develops,  and  an  amputation  nnist  be  performed,] 

Most  Common  Location  of  Varicose  Ulcers. — Varicose  ulcers  develop 
most  frequently  upon  the  internal  and  anterior  surfaces  of  the  lower 
third  of  the  leg  and  about  the  internal  malleolus;  that  is,  in  the  area 
drained  by  the  long  saphenous  vein.  More  rarely  they  develop  in  the 
area  drained  by  the  short  saphenous  vein. 

Frequently  varicose  ulcers  are  bilateral.  A  varicose  ulcer  may  be 
present  upon  one  leg,  and  on  the  other  an  eczema,  covered  with  scales  and 
crusts,  which  terminates  later  in  ulceration, 
or  a  dark-brown  pigmented  scar  resulting 
from  the  healing  of  a  previous  ulcer. 

Small  ulcers  may  develop  in  any  patient 
afflicted  with  varicose  veins.  They  rarely 
develop,  however,  before  the  fortieth  year. 
Large  ulcers  are  seen  more  frequently  in 
poor  people.  Hard  work  and  uncleanliness 
are  important  etiological  factors. 

Appeara)icc  of  Varicose  Ulcers. — Varicose 
ulcers  differ  in  appearance,  but  they  are  char- 
acteristic enough  to  enable   / 
one    to    differentiate    be- 
tween them  and  syphilitic 
or    carcinomatous    ulcers.  ''' 

The  edges  of  the  ulcer  are 
irregular,  not  undermined, 
.slope  gradually  to  the  floor 
of  the  ulcer  or  are  indu- 
rated and  hard.  The  ulcer 
is  shallow,  unless  its  edges 

are  swollen  and  edematous,  and  then  the  floor  of  the  ulcer  is  deep, 
llie  floor  of  the  ulcer  is  covered  with  a  yellow,  caseous  (Uhris  or  granu- 
lation tissue  which  is  only  in  rare  instances  healthy.  The  granulations 
oven  in  old  ulcers  are  exuberant,  flabby,  cyanotic,  or  dotted  with  small 


Fig.  209. — Varicose  Ulcer  of  the  Leg. 


508 


NECROSIS 


hemorrhages.  The  secretion  from  the  ulcer  is  profuse,  being  seropuru- 
lent  or  putrid  in  character.  Adjacent  to  the  ulcer  may  be  found  a 
delicate,  brown,  pigmented  scar,  with  shining  or  scaling  surface,  which 
is  adherent  to  the  deeper  tissues,  or  a  squamous  or  pustular  eczema. 
The  surrounding  skin  is,  as  a  rule,  oedenuitous  or  hypertrophied.  In- 
flammatory redness  is  rarely  absent. 

Differential  Diagnosis. — Syphilitic  ulcers,  due  to  regressive  changes 
in  cutaneous  or  periosteal  gunnnata,  are  so  characteristic  that  they  are 
easily  distinguished  from  varicose  ulcers.  It  is 
not  always  so  easy  to  make  a  differential  diag- 
nosis between  a  varicose  and  carcinomatous  ulcer, 
as  occasionally  a  carcinoma  develops  upon  an  old 
varicose  ulcer.  The  rapid  development  of  nodu- 
lar, hard  granulations  in  a  varico.se  ulcer  should 
always  arouse  suspicion.  The  edges  of  varicose 
ulcers  may  become  raised  by  the  development  of 
masses  of  cicatricial  tissue  and  resemble  those  of 
a  carcinomatous  ulcer. 

The  growth  of  a  varicose  ulcer  is  rarely  con- 
tinuous and  progressive.  Healing  and  ulceration 
alternate  in  the  clinical  picture.  The  ulcer,  which 
in  the  beginning  is  about  as  large  as  a  ten-cent 
piece  and  scarcely  extends  to  the  corium,  may 
heal  if  favorable  conditions  are  provided.  The 
epithelial  islands  still  remaining  between  the  pa- 
pilla proliferate  to  cover  the  ulcer.  A  delicate, 
brown,  pigmented  scar  develops,  the  circulation 
and  nutrition  of  which  are  poor.  This  scar  brealcs 
down  from  almost  any  cause  (e.  g.,  exertion,  in- 
flanniiation,  and  trauma)  and  an  ulcer  larger  and  deeper  than  the  former 
develops.  Alternating  changes,  repair  and  ulceration  may  go  on  for  a 
number  of  years.  The  development  of  large  amounts  of  cicatricial  tis- 
sue favors  Tilceration  and  the  extension  of  the  pathological  process. 
Finally  the  ulcer  may  extend  half  way  or  completely  around  the  leg, 
and  become  as  wide  as  the  hand. 

The  pain  in  varicose  ulcers  may  be  very  severe.  Ulcers  situated 
about  the  internal  malleolus  give  rise  to  the  severest  pain,  which  is 
aggravated  by  walking.  The  pain  is  often  so  severe  that  the  patient 
is  compelled  to  hold  the  foot  in  supination  while  walking.  Old  ulcci'S 
may  give  rise  to  functional  disturbances  as  the  cicatricial  tissue  extends 
deeply  and  involves  the  tendons  and  ligaments.  This  process  may  result 
in  anchylosis  of  the  ankle  joint.  The  foot  then  is  not  much  better 
as  regards  function  than  an  artificial  foot  (Nasse). 


Fig.  210. — Syphilitic  Ul- 
cer OF  THE  Leg. 


XECROSIS  RESULTING  FROM  CHRONIC  DISEASE  OF  VESSEL  WALL     509 

Varicose  ulcers  resemble  very  closely  ulcers  which  develop  upon  the 
leg  as  the  result  of  impairment  of  circulation  due  to  excessive  walking 
and  long-continued  standing.  These  ulcers  are  not  associated  with 
varicosities.  Frequently  thrombophlebitis  and  lymphangitis  develop 
from  such  ulcers;  the  veins  become  dilated  as  a  result,  and  in  this  way 
ulcer  formation  is  favored. 

Treatment. — The  following  rules  may  be  given  for  the  treatment  of 
varicose  ulcers:  (1)  Improve  the  circulation  of  the  extremity  by  rest 
and  elevation.  If  the  patient  is  up  and  about,  advise  the  use  of  a  band- 
age which  supplies  gentle  elastic  compression.  Flannel  and  jersey 
bandages,  bandages  and  stocking  of  elastic  webbing  are  to  be  preferred. 
The  latter,  however,  prevent  evaporation  and  favor  the  development  of 
eczema.  The  large  dilated  vein  should  be  resected  or  the  main  trunk 
of  the  long  saphenous  vein  ligated  or  resected  at  the  saphenous  open- 
ing, providing  its  radicals  are  involved.  [Before  operative  treatment 
is  instituted  a  careful  history  should  be  elicited  regarding  the  probable 
etiological  factors.  If  the  deep  veins  are  occluded  or  dilated,  the  opera- 
tion should  not  be  performed,  as  the  entire  venous  circulation  will  then 
be  thrown  upon  the  deep  veins,  the  blood  wall  stagnate,  and  moist  gan- 
grene of  the  extremity  w^ll  develop.  The  deep  veins  are  always  in- 
volved when  the  lesion  occurs  after  typhoid  fever  and  phlegmasia  alba 
dolens;  the  femoral  vein  is  involved  in  the  former,  the  iliac  veins  in 
the  latter.] 

(2)  Bacterial  infections  should  be  prevented  by  cleanliness,  fre- 
quent application  of  aseptic  dressings,  and  sterilization  of  the  area  sur- 
rounding the  ulcer.  The  ulcer  should  be  protected  from  external  irri- 
tation (e.  g.,  rubbing  of  clothes)  by  copious,  properly  applied  dressings. 
Moist,  antiseptic  dressings  of  aluminum  acetate  favor  the  development 
of  granulation  tissue,  the  separation  of  gangrenous  tissue,  and  the  re- 
moval of  irritating  bacterial  products.  Cauterization  of  the  ulcer  with 
silver  nitrate,  removal  of  flabby  granulations  with  the  sharp  spoon,  and 
finally  excision  of  the  indurated  cicatricial  borders  favor  repair. 

Old  chronic  ulcers  should  be  excised  and  the  fresh  defect  should 
then  be  covered  with  skin  grafts.  Cutis  grafts  are  used  more  exten- 
sively than  epidermal  grafts  for  this  purpose.  The  extremity  still  be- 
comes congested  when  it  is  dependent  or  used  in  walking,  and  epidermal 
grafts  do  not  do  well,  even  when  precautions  are  taken  to  prevent  pas- 
sive hypera'mia  of  the  limb  during  the  process  of  repair  and  for  some 
time  afterwards.  Pedunculated  flaps  taken  from  the  area  adjacent  to 
the  ulcer  or  from  the  other  leg  heal  moi-e  readily  than  non-peduneulated 
flaps. 

Unna's  zinc-gelatin  dressing,  as  used  by  neidcnhiiin,  is  recom- 
mended for  patients  who  nmst  be  up  and  about  tending  to  business. 


510  NECROSIS 

The  dressing  exerts  even  compression  upon  the  skin,  takes  up  the  secre- 
tion of  the  nicer  and  protects  it.  After  a  warm  footbath  and  steriliza- 
tion of  the  skin  of  the  leg,  eczematous  areas  are  covered  with  Lassar's 
paste,  ulcers  with  iodoform  gauze,  or,  if  granulation  tissue  has  already- 
developed,  with  salve.  A  zinc-gelatin  mixture  (zinc  oxid,  gelatin,  aa 
20.0;  glycerin,  distilled  water,  aa  80.0)  is  melted  over  a  water  bath  and 
then  the  foot  and  leg  are  painted  with  it.  A  gauze  bandage  is  then 
applied  smoothly  and  evenly  and  another  coating  of  the  zinc-gelatin  mix- 
ture is  then  applied.  Four  layers  of  bandage  and  four  coatings  of  gela- 
tin mixture  are  applied  alternately,  and  then  an  ordinary  mull  bandage 
is  applied.  The  dressing,  which  hardens  in  twenty-four  hours,  should 
be  removed  as  soon  as  the  secretion  of  the  ulcer  soaks  through  it. 

Sometimes  when  the  ulcers  are  large  and  chronic,  especially  when 
they  occur  in  old  people,  amputation  must  be  considered.  Amputation 
is  indicated  when  protracted  putrefaction  leads  to  cachexia  and  amyloid 
degeneration  of  viscera  is  feared,  when  general  infection  develops  or 
a  carcinoma  develops  upon  an  ulcer. 


CHAPTER   VI 

NEUROPATHIC    GANGRENE 

Ulcers  of  the  skin  and  mucous  membranes,  mummification  or  gan- 
grene of  the  terminal  parts  of  the  extremities  may  follow  diseases  or 
injuries  of  the  central  nervous  system  or  .of  the  peripheral  nerves. 
Nutriti(mal  disturbances,  due  to  the  loss  of  trophic  influences,  certainly 
play  a  part  in  this  form  of  gangrene,  but  other  influences,  such  as 
transitory  or  continued  pressure,  injuries,  and  inflannnation  cannot  be 
excluded. 

Tissues  deprived  of  their  nerve  supply  become  necrotic  more  fre- 
(piently  lh;ni  normal  tissues,  and  the  necrosis  develops  more  rapidly  and 
is  more  extensive.  This  is  probably  due  to  a  number  of  factors:  (1) 
the  resistance  of  the  tissues  to  bacterial  infections  is  reduced;  (2)  the 
circulalion  is  impaired  as  a  result  of  vasomotor  disturbances;  (3)  the 
area  sup])]ie(l  by  the  injured  or  diseased  nerve  is,  as  a  rule,  ann?sthetic, 
and  as  injuries  and  inflammations  are  no  longer  painful  the  lesions 
resulting  from  them  are  neglected. 

Neuroparalytic  Keratitis. — In  many  cases  keratitis  neuroparahjtica, 
aceom]);uiied  by  ulcer  formation,  follows  inflammation  and  paralysis  of 
the  trigemiiud  nerve  (resulting  from  injury,  tumors,  aneurysms,  resec- 
tion of  the  (Jasserian  ganglion  for  trifacial  neuralgia).     The  anaesthetic 


NEUROPATHIC   GANGRENE 


511 


cornea  is  more  exposed  to  external  influences  (dust,  contact  with  the 
finger)  than  the  normal,  and  its  epithelium  is  easily  injured.  Its  resist- 
ance to  infection  is  reduced  and  a  simple  conjunctivitis  may  be  the 
cause  of  a  severe  keratitis,  resulting  disastrously.  Ulceration  of  the 
anaesthetic  nuicous  membrane  — 

of  the  tongue  and  cheek  is 
usually  the  result  of  injuries 
by  the  teeth. 

Sometimes  ulcers,  at  other 
times  dry  gangrene,  develop 
upon  the  trunk  and  extremi- 
ties as  the  result  of  diseases 
and  injuries  of  the  central 
and  peripheral  nervous  sys- 
tem. The  disease  or  injury  is 
the  predisposing  cause,  but 
usually  there  are  a  number 
of  determining  causes.  The 
necrosis,  however,  is  never  ex- 
tensive, unless  moist  gangrene 
develops. 

Acute  Decubitus  in  Para- 
plegia and  Hemiplegia. — 
Acute  decubitus  develops  fre- 
quently in  hemiplegias  and 
paraplegias  of  whatever  ori- 
gin (cerebral  and  spinal  tu- 
mors, hemorrhages  into  the 
spinal  cord,  or  injuries). 

It  may  develop  upon  any 
part  exposed  to  slight  pres- 
sure, most  frequently  in  the 
sacral  region,  the  back,  or 
over  the  heel.  The  lesions 
may  become  quite  extensive, 
as  the  area  is  antesthetic  and 
they  are  not  discovered  until 
late  unless  the  doctor  or  nurse 
anticipates  them.  In  locomo- 
tor ataxia  and  paralysis  of 
the  lower  extremities,  espe- 
cially in  spina  bifida,  dry, 
painless    ulcers     (perforating 


Fig.  211 


Decubitus  in  a  Paralytic  Club  Foot 
Associated  with  a  Spina  Bifida  Occulta  with 
Hyi'ertrichiasis. 


512  NECROSIS 

ulcers),  which  resist  treatment,  develop  in  the  sole  of  the  foot.  The 
ulcers  develop  from  a  callosity,  a  fissure,  or  an  insignificant  injury. 
Similar  ulcers,  which,  however,  are  usually  accompanied  by  severe  pain, 
may  develop  in  neuritis.  In  syringo-myelia  and  the  nervous  form  of 
leprosy,  painless,  dry  gangrene  as  well  as  ulcers  due  to  pressure  necrosis 
develops  upon  the  fingers.  In  leprosy  the  toes  may  also  be  involved. 
After  the  separation  of  the  necrotic  parts  the  involved  extremity  is 
crippled  and  transformed  into  a  short  cicatricial  stump.  After  injury 
of  the  nerves  of  the  extremities,  small,  deep,  painless  ulcers  may  de- 
velop upon  the  palmar  surfaces  of  the  fingers  and  the  sole  of  the  foot 
from  ruptured  vesicles  or  blebs. 

Raynaud's  Disease. — Symmetrical  gangrene,  or  Raynaud's  disease, 
and  perforating  ulcer  of  the  foot  {malum  perforans,  Nelaton)  are  pe- 
culiar forms  of  gangrene  and  ulcer,  the  etiology  and  exact  classification 
of  which  are  not  at  all  clear.  It  is  doubtful  whether  it  is  correct  to 
maintain  that  they  are  distinct  clinical  entities. 

The  form  of  gangrene  designated  as  Raynaud's  disease  develops  in 
young  (especially  anamiic)  people,  also  in  children.  In  this  disease  a 
dry,  usually  symmetrical,  gangrene  develops  upon  the  fingers,  more 
rarely  upon  the  toes,  the  ears,  the  cheeks,  and  the  nose.  It  begins  with 
nervous  and  vasomotor  disturbances,  similar  to  those  to  be  described  later 
in  ergotism. 

Pallor  and  coldness  of  the  part  involved,  the  symptoms  of  local 
ischa^mia  (local  syncope),  follow  the  prodromal  stage  of  severe  pain  and 
paraesthesias  (formication  and  numbness).  The  pallor  and  coldness 
may  disappear  or  the  skin  may  become  bluish  red  in  color  (local  cyano- 
sis, asphyxia) ,  and  necrosis,  usually  of  the  terminal  phalanges  only,  with 
vesicle  and  crust  formation,  develops.  The  entire  course  of  the  disease 
may  extend  over  months  and  years  and  be  combined  with  scleroderma. 
Roentgen-ray  pictures  indicate  the  disappearance  of  the  terminal  pha- 
langes. Nothing  definite  is  known  concerning  the  vascular  spasm  which 
is  peculiar  to  the  beginning  of  Raynaud's  disease.  Inflammatory  changes 
have  been  found  in  the  vessels  and  nerves,  but  they  are  not  constant. 
According  to  Cassirer,  the  irritability  of  the  vasomotor  tracts  and  cen- 
ters is  increased  as  the  result  of  some  congenital  predisposition  or  some 
frecjuently  repeated  harmful  inliuence,  sucli  as  cold,  infectious  diseases, 
or  poisoning — for  example,  with  chloral  and  phosphorus.  Severe  psy- 
chical disturbances  (fright)  have  also  been  suggested  as  etiological  fac- 
tors. Usually  tlici-e  is  no  disease  of  the  central  nervous  system.  Symp- 
toms of  Raynaud's  disease  may  develop,  however,  during  the  clinical 
course  of  locomotor  ataxia,  syringo-myelia,  epilepsy,  hysteria,  exoph- 
llialiiu'c  goiter,  and  tumors  of  the  spinal  cord   (X^ppenheim). 

Soiiicliincs   wjicii   llici'e  is   but  little  pain   and  the  symptoms  of  the 


NEUROPATHIC   GANGRENE 


513 


disease  are  not  pronounced,  it  is  very  difficult  to  differentiate  Raynaud's 
disease  from  syringo-niyelia  and  leprosy.  Both  syphilitic  and  angio- 
sclerotic gangrene  may  be  symmetrical,  and  as  they  may  be  accompanied 
by  severe  pain,  they  may  resemble  closely  gangrene  occurring  in  Ray- 
naud's disease. 

Ergot  Gangrene.^Gangrene  occurring  in  chronic  ergot  poisoning 
(ergotism)  is  probably  due  to  angiospasm.  Cases  of  ergot  gangrene  are 
rarely  seen  at  the  present  time  (except  in  Southern  Russia,  Zoege  von 
Manteuffel),  although  it  was  very  connnon  in  the  IMiddle  Ages.  It  fol- 
lows the  use  of  diseased  rye  in  the  making  of  bread.  The  severe  cases 
end  fatally  in  a  few  days,  the  symptoms  consisting  of  sensory  disturb- 
ances (formication,  pain,  or  ana\stliesia) ,  convulsions,  vomiting,  and 
diarrhoea.  In  the  milder  cases  the  symptoms  of  ischa^mia  develop  espe- 
cially in  the  distal  parts  of  the  lower  extremities,  as  a  result  of  the  con- 
traction of  the  walls  of  the  blood  vessels.  Pain  is  first  noted  in  the 
parts  involved  which  later  become  pale,  cold,  and  aniesthetic.  As  the 
disease  advances  the  parts  become  C3'anotic,  and  then  a  dry  or  a  moist 
gangrene  develops.  Billroth  describes  a  case  of  ergot  gangrene  of  the 
fingers  which  followed  the  administration  of  large  doses  of  this  drug 
for  medicinal  purposes. 

Perforating  Ulcer. — By  perforating  ulcer  (malum  perfomns  pedis) 
is  understood  a  chronic,  painless  form  of  ulcer  which  resists  treatment 
and  recurs  without  any  apparent  cause.  It  may  develop  upon  any 
part  of  the  foot,  most  conniionly,  however, 
at  the  three  points  on  the  plantar  surface 
which  are  constantly  exposed  to  pressure 
when  the  patient  stands  or  walks.  These 
three  points  are  the  heads  of  the  first  and 
fifth  metatarsal  bones  and  the  heel.  The 
area  surrounding  the  ul- 
cer is  anaesthetic  or  anal- 
gesic, and  there  are,  as 
a  rule,  trophic  changes 
in  the  skin  and  nails. 
Necrosis  follows  a  sup- 
purative inflannnation 
Avliich  develops  beneath 
a  callosity,  in  a  small 
wound  or  an  accessory  bursa.  The  necrosis  progresses  sbiwly  and 
a  deep,  funnel-shaped  ulcer  with  precipitous  and  undermined  edges 
forms.  It  may  heal  tempoi'arily  and  then  break  down  again.  Repair 
and  ulceration  may  alternate  for  a  number  of  years,  and  the  ulcei- 
may  eventually  afford  the   infection  atrium   for  a  severe   putrefactive 


Fig.  212. — Pkkfokating  Ulckk  of  the  Foot  in 
Locomotor  Ataxi.\, 


514  NECROSIS 

infection  ending  in  disorganization  of  neighboring  joints  and  destruc- 
tion of  bone. 

Perforating  ulcers  follow  diseases  and  injuries  of  the  central  nervous 
system  and  peripheral  nerves  (for  this  reason  they  are  called  neuro- 
paralytic ulcers  by  Duplay,  Morat,  H.  Fischer,  and  others).  They  are 
frequently  found  in  locomotor  ataxia,  syringo-myelia,  spina  bifida  (Fig. 
211),  injuries  and  diseases  of  the  vertebrae  with  involvement  of  the  spinal 
cord,  paretic  dementia,  injuries,  tumors,  and  inflammation  of  the  nerves. 
Disease  of  the  vessels,  which  is  sometimes  found,  cannot  be  regarded  as 
the  cause  of  the  ulcer  (Nasse). 

This  form  of  ulcer  also  occurs  in  diabetes  as  a  result  of  an  accom- 
panying neuritis.  It  differs  from  diabetic  gangrene  proper  in  the 
absence  of  pain. 

Ulcers  due  to  other  causes — for  example,  old,  neglected  wounds  and 
ulcers  occurring  in  angiosclerosis  and  syphilis — may  be  easily  differen- 
tiated from  perforating  ulcers,  as  they  are  painful  and  there  are  no 
accompanying  sensory  disturbances. 

The  small  multiple  foci  of  cutaneous  necrosis  (multiple  neurotic  ne- 
crosis of  the  skin,  herpes  zoster  gangr»nosus,  Kaposi,  gangrenous  urti- 
caria, Renaut),  which  may  be  distributed  over  the  entire  surface  of  the 
body  are  probably  due  to  changes  in  the  nervous  system.  Hysterical 
patients  occasionally  produce  a  necrosis  of  the  skin  with  caustic  soda, 
which  resembles  this  form  very  closely  (Cassirer). 

Treatment. — The  first  indications  in  the  treatment  of  necrosis  of  neu- 
ropathic origin  are  to  remove  the  cause  when  possible  and  to  treat  the 
principal  disease.  Otherwise  the  same  rules  that  have  been  given  for 
the  treatment  of  angiosclerotic  gangrene  should  be  followed.  The  cica- 
tricial edges  of  the  ulcers  should  be  excised  in  order  to  provide  good 
drainage  for  the  secretion ;  moist  dressings  and  hot  baths  favor  the  devel- 
opment of  granulation  tissue  and  healing.  Necrotic  bone  should  be 
removed,  joints  destroyed  by  suppuration,  resected.  Recurrence  may 
follow  excision  of  the  ulcer.  According  to  Chipault,  permanent  healing 
may  be  secured  if  at  the  time  the  ulcer  is  excised  the  nerves  about  the 
ankle  are  stretched. 

Literature. — Adrian.  Das  Mai  perforant.  Centralbl.  f.  Grenzgeb.,  1904,  p.  321. 
— Barrawl.  Ueber  Extremitatengangriin  im  jugendlichen  Alter  nach  Infektions- 
krankheiten.  Deutsche  Zeitschrift  f.  Chir.,  Bd.  74,  1904,  p.  237.— Sec/c.  Some  New 
Points  in  Regard  to  Raynaud's  Disease.  Amer.  Journal,  November,  1901. — Bergmann 
(Morian).  Ueber  Gefassverletzungen  in  der  Kniekehle.  Festschr.  zur  Huyssenstif tung, 
Essen,  1904. — v.  Bergmann.  Die  isolierte  Unterbindung  der  Vena  femoralis  communis. 
Wiirzburger  Festschr.,  1882; — Die  Schussverletzungen  der  Art.  subclavia,  etc.  St. 
PeterslMirgcr  Wochenschr.,  1877.— Brandweiler.  Multiple  neurotische  Hautgangriin. 
Monatshefte  f.  prakt.  Dermatol.,  Bd.  39,  No.  5. — Cassirer.  -Ueber  nuiltiple  neurotische 
Hautgangriin.     Zentralbl.  f.  Grenzgeb.,  1900,  p.  101. — Chipault.     Radikalbehandlung 


NEUROPATHIC    GAXGREXE  515 

des  Mai  perforant  clurch  Nervendehiuuis-  Oaz.  des  hop.,  No.  41,  1901. — Elsenberg. 
Die  sogenannte  Raynaudsche  Kraukhuit  (Grangraena  symmetrica)  sjq)hilitischen 
Ursprungs.  Arch.  f.  Dermatol,  urid  Syphil.,  Bd.  24,  1892,  p.  577. — Krb.  Ueber 
Bedeutung  und  praktischen  Wert  der  Fussarterien  bei  gewissen  anscheinend  nervosen 
Erkrankungen.  Mitteil.  aus  d.  Grenzgeb.,  Bd.  4,  1900. — Fraenkel.  Ueber  Verletzung 
der  Vena  fern,  communis  und  deren  Behandlung.  Beitr.  z.  klin.  Chir.,  Bd.  30,  1901,  p. 
SI. — Frankenburger.  Ueber  Karbolgangran.  I.-D.  Erlangen,  ,1891. — Franz.  Zur 
Unterbindung  der  Vena  femoralis  am  Lig.  Poup.  Deutsche  militariirztl.  Zeitschr., 
19():i,  Hit.  9.—Goedecke.  Spontane  Gangran  an  den  vier  Extremitaten.  Verhandl.  d. 
freien  Chirurgenvereinig.  Berlin,  1903,  Jahrg.  16. — Groszmann.  Ueber  Gangran  bei 
Diabetes  mellitus.  Berlin,  1900,  Hirschwald. — Haga.  Ueber  spontane  Gangran. 
Virchow's  Arch.,  Bd.  152,  1898,  p.  26.— Higier.  Zur  Myasthenia  paroxysmalis  angio- 
sclerotica  und  der  sog.  spontanen  Gangran.  Zentralbl.  f.  Chir.,  1901,  p.  1080. — Hilde- 
brandt.  Ueber  diabetische  Extremitiitengangran.  Deutsche  Zeitschr.  f.  Chir.,  Bd. 
72,  1904,  p.  35l.—Hon^ell.  Ueber  Karbolgangran.  Beitr.  zur  klin.  Chir.,  Bd.  19, 
1897,  p.  623. — Hopfner.  Ueber  Gefassnaht,  u.  s.  w.  Arch.  f.  klin.  Chir.,  Bd.  70,  1903, 
p.  417. — Kausch.  Beitrage  zum  Diabetes  in  der  Chirurgie.  Chir.-Kongr.  Verhandl. 
1904,  II,  p.  655. — Lcvai.  Ueber  Mai  perforant  du  pied.  Deutsche  Zeitschr.  f.  Chir., 
Bd.  49,  1898,  p.  558. — Matanowitsch.  Zur  Kasuistik  der  Spontangangran.  Beitr. 
z.  klin.  Chir.,  Bd.  29,  p.  545,  1901. — v.  Mikulicz  und  Kausch.  Embolie  und  Thrombose 
der  Mesenterialgefasse.  Handb.  der  prakt.  Chir.,  2.  Aufl.,  BiL  3,  p.  386. — Milhsam. 
Doppelseitige  Oberschenkelamputation  wegen  akuter  Gangran.  Deutsche  Zeitschr. 
f.  Chir.,  Bd.  70,  1903,  p.  333.— FriYz  Midler.  Ueber  Gangran  von  Extremitaten  bei 
Neugeborenen.  I.-D.  Strassburg,  1900. — Nasse.  Krankheiten  der  unteren  Ex- 
tremitaten. Deutsche  Chir.,  1897. — Oppenheim.  Lehrbuch  der  Nervenkrankheiten. 
Berlin,  Karger. — Raynaud.  De  I'asphyxie  locale  et  de  la  gangrene  sym(5trique  des 
extremites.  Paris,  1862. — Rotter.  Die  Stichverletzungen  der  Schliisselbeingefasse. 
V.  Volkmann's  Samml.  klin.  Vortr.,  N.  F.,  No.  72,  1893. — v.  Recklinghausen.  Handb.  der 
allgem.  Patholog.  des  Kreislaufes  und  der  ErnJihrung.  Deutsche  Chir.,  1883. — Roosen- 
Rungc.  Ueber  die  Bedeutung  des  Traumas  in  der  Aetiologie  der  disseminierten  Fettge- 
Avebsnekrose.  Zeitschr.  f.  klin.  Med.,  Bd.  45,  p.  418. — Franz  Rosenberger.  Ursachen 
der  Karbolgangran  (experimentelle  Untersuchungen).  Wiirzburg,  Stuber,  1901. — 
V.  Wartburg.  Ueber  Spontangangran  der  Extremitaten.  Beitr.  z.  klin.  Chir.,  Bd.  35, 
1902,  p.  624;— Ueber  das  Mai  perforant  des  Fusses.  Ibid.,  Bd.  36,  1902,  p.  212. — 
0.  Weber.  Von  dem  Brande.  v.  Pitha  und  Billroth's  Handb.  der  Chir.,  1865,  1.  Bd.,  1. 
part. — //.  Wolf.  Diabetische  Gangran  und  ihre  Behandlung.  Sammelreferat. 
Zentralbl.  f.  Grenzgeb.,  1901,  p.  21. — Wormser.  Ueber  puerperale  Gangran  der  E.x- 
treinitiiten.  Wien.  klin.  Rundschau,  1904,  Nos.  5-6. — Wuljf.  Ueber  Spontangangran 
jugendlicher  Individuen.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  58,  1901,  p.  478. — Ziegler. 
rchcr  Stichverletzungen  der  grossen  Gefiisse  der  Extremitaten.  Miinch.  med.  Wochen- 
schr.,  1897,  p.  733. — Zoege  v.  Mnnteujfel.  Die  Arteriosklerose  der  unteren  Extremitaten. 
Mitt,  aus  dem  Grenzgeb.,  Bd.  10,  1902. 


PART   IV 


INJURIES  OF  THE  SOFT   TISSUE,  BONES  AND 
JOINTS   AND   THEIR   TREATMENT 


An  injury  is  an  alteration  in  the  tissues  induced  by  the  application 
of  some  force,  the  results  of  which  are  the  separation  of  the  injured  tis- 
sues from  their  normal  connections,  an  alteration  of  their  normal  struc- 
ture, or  a  disturbance  of  nervous  activity  such  as  is  seen  in  shock.  The 
injurious  agents  (the  so-called  traumas),  as  well  as  the  results  following 
their  action,  are  widely  different.  Injuries  are  classified  as  mechanical, 
chemical,  and  thermal. 


I.    THE   MECHANICAL   INJURIES 

CHAPTER   I 

GENERAL    CLASSIFICATION    OF    MECHANICAL   INJURIES 

We  recognize  the  following  forms  of  injuries:  contusions,  lacera- 
tions, and  concussions,  and  special  varieties  occurring  in  certain  systems 
only,  such  as  fractures  of  bones,  dislocations  of  joints,  and  subluxations 
of  tendons  and  nerves. 

A  contusion  is  an  injury  which  follows  a  compression  of  the  tissues 
beyond  tlieir  ])()W('i's  of  resistance.  The  action  of  blunt  force  or  the  strik- 
ing of  a  part  of  the  body  upon  a  hard  ()l)ject  are  the  most  usual  causes. 
The  soft  i)arts  are  either  compressed  against  the  bone,  or  are  caught 
between  two  rcsist.int  sui'i'aces — the  most  usual  meclianism  when  the 
larger  parts  of  the  body  are  injured — which  ai-e  forced  together  like 
the  arms  of  a  pair  of  tongs.  The  contusion  is  limited  to  those  tissues 
acted  upon  l)y  the  compressing  surfaces  or  to  all  those  compressed  be- 
tween the  object  find  ])i-ojections  or-  edges  of  the  bone.  The  skin,  being 
more  r(>sistant  thnn  fnt  and  nniscle,  may  remain  practically  intact,  even 
when  the  subjacent  soft  tissues  ai-e  transfoniuHl  into  a  pulpy  mass  and 
are  separated  from  all  their  iioi'inal  connections. 
516 


GENERAL  CLASSIFICATION   OF   MECHANICAL   INJURIES         517 

A  contusion  is  not  only  a  compression  of  the  tissues,  but  is  also,  and 
according  to  Gussenbauer,  is  principally,  a  laceration  of  the  tissues 
which  follows  a  stretching-,  beyond  their  greatest  point  of  elasticity. 

According  to  Gussenbauer,  in  the  jnildest  contusions  the  changes  are 
limited  to  a  separation  of  the  loose  connective  tissues  and  a  tearing  of 
the  smallest  lymphatic  and  blood  vessels,  while  in  the  severer  contusions 
the  intercellular  substance  is  lacerated.  lie  finds  that  the  greater  part 
of  the  cellular  elements  may  be  retained  even  in  the  severest  crushing 
injuries,  in  which  the  tissues  may  be  completely  separated  from  each 
other. 

The  common  sumptoms  of  a  contusion  are  pain,  loss  of  function,  and 
swelling  which  follows  ha?morrhage  from  the  torn  vessels.  Associated 
with  these  symptoms  is  the  discoloration  of  the  surface  following  changes 
in  the  extravasated  blood. 

Lacerations  are  injuries  which  follow  stretching  of  the  tissues  by  a 
wrench  or  traction,  the  blunt  force  being  either  applied  obliijuely  or 
acting  from  within  the  body.  If  the  tissues  are  stretched  beyond  their 
own  degree  of  elasticity,  the  intercellular  substance,  rarely  the  paren- 
chyma proper,  is  lacerated.  If  the  gross  anatomical  structure  is  pre- 
served, one  speaks  of  a  stretching  or  tearing ;  if  the  tissues  are  separated, 
of  a  rupture.  If  the  skin  is  torn,  the  wound  is  spoken  of  as  a  lacerated 
wound,  and  when  the  force  has  acted  from  withni,  as  a  bursting  wound. 

Pain,  impairment  of  function,  and  swelling  due  to  the  extravasated 
blood  are  the  most  important  symptoms. 

Concussion  is  the  term  employed  to  indicate  the  condition  induced 
by  the  action  of  blunt  force  (thrust,  blow,  fall)  which  is  not  powerful 
enough  to  cause  demonstrable  changes  in  the  tissues,  such  as  a  solution 
of  continuity.  The  effects  of  the  concussion  may  extend  immediately 
to  the  large  parts  of  the  body  or  remain  limited  to  the  part  to  which 
the  force  was  applied,  in  which  case  it  is  usually  associated  Avith  a  contu- 
sion or  laceration.  The  symptoms,  consisting  of  pain,  partial  or  com- 
plete loss  of  sensation  and  motion,  are  due  to  alterations  in  nervous 
tissue.  Concussion  of  the  tissues  adjacent  to  contused  wounds  is  com- 
mon, the  symptoms  being  grouped  under  the  term  local  shock  or  wound 
stupor.  The  symptoms  associated  with  a  concussion  soon  disappear 
unless  the  tissues  are  contused  or  lacerated. 

Examples  of  concussion  are  known  to  all  through  personal  experience. 
When  one  jumps  some  distance  and  alights  upon  a  hard  surface,  the 
lower  extremities  being  held  stiff,  a  concussion  is  experienced.  A  dull 
pain  passes  through  the  legs,  which  are  momentarily  numb  and  palsied. 
The  numbness  quickly  gives  way  to  a  tingling  sensation,  and  the  latter, 
after  a  time,  to  a  feeling  of  weakness.  Similar  sensations  may  be  expe- 
rienced following  a  slight  injury  of  the  ulnar  nerve  behind  the  internal 


518  THE  MECHANICAL   INJURIES 

condyle,  the  sensory  disturbance  extending  even  to  the  area  supplied  by 
the  terminal  filaments  of  the  nerve. 

Concussion  of  the  brain  and  the  rarer  forms  of  concussion  of  the 
spinal  cord,  thorax,  and  abdomen  are  more  dangerous,  and  not  infre- 
quently end  fatally.  In  these  cases  the  symptoms  are  rarely  due  to  the 
concussion  alone,  but  are  combined  with  those  due  to  severe  crushing 
injuries  and  internal  haemorrhage,  and  may  pass  imperceptibly  into  those 
of  severe  inflammation. 

The  chief  symptoms  of  concussion  of  the  brain  following  injuries 
of  the  skull  are  loss  of  consciousness  and  defects  of  memory  following 
the  return  of  consciousness.  These  are  due  to  some  injury  of  the  nerve 
centers,  the  exact  nature  of  which  is  unknown.  There  is  a  good  deal 
of  doubt  concerning  concussion  of  the  spinal  cord,  and  the  cases  which 
have  been  regarded  as  such  were  probably  contusions  or  lacerations  of 
the  cord  following  hyperflexion  of  the  spinal  column.  Reflexes  play  an 
important  part  in  concussions  of  the  thorax  and  abdomen,  and  for  this 
reason  they  are  frequently  classified  with  shock.  In  these  cases  there  is 
a  paralysis  of  the  vasomotor  apparatus  or  a  stimulation  of  the  cardio- 
inhibitory  centers  caused  by  irritation  of  the  vago-sympathetic,  splanch- 
nic, or  sensory  nerves. 

Frequently  an  injury  cannot  be  placed  in  any  of  the  groups  above 
mentioned,  as  it  may  be  a  combination  of  two  or  more  varieties.  For 
example,  a  fragment  of  a  bomb  may  contuse  and  lacerate  the  tissues  and 
produce  a  concussion  at  the  same  time.  A  bullet  may  injure  the  soft 
tissue  and  pass  to  the  bone.  The  latter  is  comminuted,  and  the  soft 
tissues  are  not  only  injured  by  the  bullet,  but  by  the  fragments  and 
fractured  ends  of  the  bone  as  well;  concussion,  laceration,  and  contusion 
of  the  tissues  being  combined.  A  laceration  is  always  associated  with  a 
contusion  when  the  force  is  applied  obliquely  to  the  surface  of  the  body. 

Literature. — Gussenbauer.     Die    traumatischen    Verletzungen.     Deutsche    Chir., 
1880. 


CHAPTER    II 

MECHANICAL   INJURIES   OK    THE   DIBTERENT   TISSUES 

I.     INJURIES  OF  THE  SKIN,  SUBCUTANEOUS  TISSUES  AND 
MUCOUS  MEMBRANES 

Besides  the  8im])l('  wounds,  wliicli  have  already  been  described 
(Chapter  I),  excoriation  and  contusion  of  and  extravasation  of  blood  into 
the  skin  also  occur.     Excoriations  are  most  usually  i)roduced  by  a  fall, 


MECHANICAL   INJURIES   OF   THE    DIFFERENT   TISSI'ES  519 

bcin*:^  observed  frequently  npoFi  tlie  knees  and  chins  of  children,  or  are 
associated  with  injuries  produced  by  blunt  force.  The  epidermis  is 
scraped  away  when  the  part  ylides  upon  the  floor  after  a  fall  or  when 
blunt  force  is  applied  tangentially.  The  corium,  which  bleeds  easily  and 
is  painful,  is  then  exposed,  being  frequently  covered  by  gross  particles 
of  dirt.  The  exposed  surface  soon  becomes  covered  with  a  crust  as  the 
blood  and  tissue  fluids  rapidly  coagulate.  Healing  without  scar  forma- 
tion occurs  beneath  the  crust,  providing  suppurative  or  phlegmonous 
inflammation,  lymphangitis,  and  erysipelas  do  not  develop. 

In  the  trcaimeni  the  grosser  particles  of  dirt  (sand,  splinters  of 
wood)  which  have  been  forced  into  the  tissues  should  be  removed  with  tis- 
sue forceps.  The  excoriation  shoidd  then  be  washed  with  a  three  per  cent 
solution  of  hydrogen  peroxid,  after  the  adjacent  area  has  been  carefully 
sterilized.  A  dry  aseptic  dressing  should  be  applied  to  prevent  infection 
if  the  crust  falls  otf,  and  especially  to  protect  against  injury  by  scratch- 
ing and  removal  of  the  crust  when  the  injured  area  itches. 

Sinqjle  contusions  of  the  skin  pursue  dilferent  clinical  courses.  When 
the  skin  lies  directly  over  a  bone,  no  soft  tissues  intervening,  the  injury 
may  be  severe  enough  to  render  the  area  bloodless  and  insensitive,  necro- 
sis developing  later.  On  tli*e  other  hand,  a  contusion  of  the  skin  may 
be  followed  by  a  subcutaneous  hti'morrhage,  indicated  by  the  appear- 
ance of  a  discoloration  which  disappears  slowly,  and  is  due  to  the  ex- 
travasation of  blood  into  the  loose  tissues  or  by  the  development  of  a 
bleb  with  ha:'morrhagic  or  serohasmorrhagic  contents  (blood  blister).  In 
order  to  prevent  infection,  these  blebs  should  not  be  opened,  but  should 
be  protected  with  dry  aseptic  gauze  attached  by  adhesive  strips.  They 
dry  up  after  a  few  days.  A  new  epithelium  develops  beneath  the  old 
epidermis  and  the  crust,  which  gradually  become  separated.  Injured 
blebs  should  be  treated  like  those  developing  in  gangrene — i.  e.,  they 
should  be  removed  and  the  resulting  w^ound  slK^uld  then  be  covered  with 
a  dry  aseptic  dressing. 

Petechiae,  Suggillations,  Hsematomas. — The  subcutaneous  tissues  may 
be  contused  and  torn  as  the  result  of  the  action  of  blunt  force  without 
any  injury  of  the  elastic  and  easily  displaceable  overlying  skin.  An 
extravasation  of  blood,  which  either  infiltrates  or  separates  the  loose  tis- 
sues, is  the  result  of  such  an  injury.  A  hgemorrhagic  infiltration  follows 
bleeding  from  capillaries  and  numerous  small  vessels;  a  hannatoma 
(blood  tumor),  bleeding  from  a  single  artery  or  vein  of  small  or  large 
diameter.  If  the  haemorrhagic  foci  are  small  and  form  more  or  less 
sharply  defined,  punctate,  red  or  reddish  black  spots,  we  desigiuite  them 
as  petechia?  or  ecchymoses;  if  they  are  larger  and  less  clearly  defined, 
as  suggillations  and  as  bloody  eifusions.  If  the  skin  is  closely  related  to 
bone,   the   fascia  and   periosteum,   which  are  usually   also   injured,   are 


520  THE   MECHANICAL   INJURIES 

infiltrated  with  blood.     In  haemophilia  very  insignificant  injuries  may 
be  followed  b.y  the  development  of  large  luematomas. 

The  haemorrhage  from  the  injured  vessels  usually  subsides  rapidly, 
for  the  lumina  are  closed  by  the  pressure  and  the  coagvilation  of  the 
extravasated  blood.  Coagulation  is  never  complete  in  large  luvmatomas, 
as  the  extravasated  blood  is  mixed  with  lymph,  which  coagulates  very 
slowly  and  interferes  with  the  coagulation  of  blood. 

AhsorptioH  of  a  Blood  Clot. — An  ha-morrhagic  infiltration  is  absorbed 
more  rapidly  and  completely  than  a  ha'matoma.  The  serum  which  is 
separated  during  coagulation  of  the  blood  is  absorbed  first;  a  large  num- 
ber of  leucocytes  being  carried  with  it  into  the  adjacent  lymph  nodes. 
The  clot  itself  is  gradually  prepared  for  absorption  by  the  digestive 
action  of  ferments  liberated  by  the  leucocytes  and  the.  cells  of  the  sur- 
rounding tissues.  Ihpmoglobin  liberated  by  the  degeneration  of  red 
blood  cells  penetrates  with  the  serum  the  surrounding  tissues,  causing 
discoloration.  The  greater  part  of  the  haemoglobin  which  is  set  free  is 
finally  absorbed  and  excreted  by  the  liver  as  bile  pigments  and  through 
the  kidneys.  Some  of  it,  after  having  undergone  a  modification,  remains 
in  the  tissues  as  a  yellow,  granular  iron-containing  pigment  known  as 
h(vmosidcrin  and  as  hamiatoidin  crystals,  which  are  ruby  red  in  color 
and  needlelike  or  rhomboid  in  shape.  These  derivatives  of  haemoglobin 
may  be  found  within  the  cells  or  lie  free  in  the  tissues. 

While  these  changes  are  going  on,  the  fibrin  and  injured  and  dead 
tissues  are  being  absorbed,  infiltrated,  and  replaced  by  granulation  tis- 
sue. The  resulting  connective-tissue  mass — the  scar — is  usually  firmer 
than  the  surrounding  tissues. 

Symptoms  of  a  Subcutaneous  TlcemorrJiagc. — The  symptoms  of  a  sub- 
cutaneous haemorrhage  are  moderate  pain,  a  bluish  red  discoloration  of 
the  skin,  which  is  more  marked  the  looser  the  tissues  (being  most  marked, 
for  example,  in  the  eyelids  and  scrotum),  and  the  development  of  a  more 
or  less  circumscribed  swelling  which  fluctuates  or  crepitates,  depending 
upon  whether  the  blood  remains  fluid  or  coagulates.  Pulsating  ha^na- 
tomas  develop  after  the  injury  of  large  arteries  (vide  p.  552).  Circum- 
scribed hematomas  ai-e  characterized  by  the  gradual  induration  of  their 
edges,  due  to  the  formation  of  a  clot.  An  aseptic  fever  may  be  associated 
with  the  larger  extravasations  of  blood. 

Cli'Hical  Course. — The  pain  and  swelling  disappear  after  several  days 
or  weeks,  depending  upon  the  amount  of  blood  which  has  been  poured 
out  into  the  tissues.  The  discoloration  may  extend  over  a  wide  area 
within  the  first  week;  for  example,  the  discoloration  associated  with  a. 
hematoma  beneath  the  skin  of  the  shoidder  may  extend  over  the  entire 
upper  arm  and  adjacent  side  of  the  chest,  increasing  in  size  as  the 
haemoglobin  penetrates  the  various  layers  of  tissue.     The  discoloration 


MECHANICAL   INJURIES  OF   THE   DIFFERENT   TISSUES  521 

is  at  first  of  a  piii-plish  hue;  later  it  becomes  bright  green  and  linally 
yellow,  the  latter  color  being  the  most  persistent. 

Treatment. — The  application  of  a  bandage  exerting  mild  compres- 
sion is  the  best  treatment  that  can  be  employed  during  the  first  few 
days,  provided  there  is  no  inflammatory  reaction.  It  relieves  pain,  pro- 
motes absorption,  and  prevents  further  haemorrhage  which  might  pos- 
sibly occur  during  movements.  The  ice  bag  and  cold  applications  are 
to  be  especially  recommended  in  the  treatment  of  subcutaneous  and  deep 
haemorrhages.  ]\Iassage  is  of  value  when  the  haemorrhage  has  ceased,  as 
it  hastens  the  absorption  of  the  clot.  Aspiration  is  indicated  if  the 
luT'matoma  is  absorbed  slowly;  incision,  if  suppuration  occurs. 

Blood  Cysts. — Larger  hamiatomas  in  the  subcutaneous  as  well  as  in 
the  nuiscular  and  retroperitoneal  tissues,  likewise  small  extravasations 
in  the  brain,  frequently  pursue  a  clinical  course  different  from  that 
described  above.  Absorption  does  not  take  place  rapidly  from  the  con- 
nective-tissue wall  lined  with  fibrin  surrounding  the  blood  clot,  and  the 
fluid  part  of  it  becomes  transformed  into  a  brownish  red,  chocolate 
colored,  thin  or  thick  mass  which  contains  blood  pigment,  lupmatoidin 
and  cholesterin  crystals,  the  last  being  apparently  derived  from  degen- 
erating fat.  The  wall  of  the  cavity  eventually  becomes  transformed 
into  thick  fibrous  tissue  which  may  later  become  calcified,  or,  if  situated 
near  a  bone,  ossified.  Traumatic  blood  cysts  are  formed  in  this  way. 
If  aspiration  of  the  contents  and  subsequent  injection  of  some  irritating 
substance,  such  as  alcohol,  iodin,  carbolic  acid,  or  iodoform  enuilsion, 
do  not  cause  the  obliteration  of  such  a  cyst,  it  should  be  incised  and 
its  walls  partially  or  completely  removed. 

Post-operative  Haematomas. — A  ha'matoma  may  develop  in  an  opera- 
tion-wound, following  haemorrhage  from  some  vessel  which  has  not  been 
ligated.  The  fluid  blood  then  trickles  from  the  spaces  between  the 
stitches  and  saturates  the  dressings;  the  clots  separate  the  tissues  form- 
ing cavities,  and  cause  severe  pain  by  exerting  pressure  upon  them.  If 
a  ha'matoma  develops  in  an  operation-wound,  the  skin  surrounding  it 
should  be  sterilized,  a  few  or  all  of  the  sutures  removed,  and  the  clots 
expressed  by  digital  pressure  applied  to  the  edges  of  the  wound.  Dur- 
ing the  manipulation  the  fingers  should  not  come  in  contact  with  the 
wound.  If  the  bleeding  vessel  is  found,  it  should  be  ligated.  The 
wound  should  then  be  tamponed  with  iodoform  gauze  and  no  attempt 
should  be  made  to  suture  it  for  several  days.  Carelessness. in  the  con- 
trol of  haemorrhage  is  frequently  followed  by  the  development  of  a 
haematoma.  Severe  inflammations  frequently  develop  in  such  wounds, 
as  infection  may  be  easily  introduced  during  the  removal  of  the  clot. 

In  all  operative  work  blood  vessels  should  be  grasped  with  artery 
forceps  as  soon  as  cut,  for  the  walls  of  the  smaller  vessels  collapse,  and 
34 


522  THE   MECHANICAL   INJURIES 

they  are  then  found  with  more  or  less  difficulty.  These  arteries  are 
often  opened  again  when  the  patient  awakes  and  the  blood  pressure 
becomes  higher.  Careful  ha^mostasis  prevents  the  development  of 
hematomas.  Post-operative  h^ematomas  develop  quite  frequently  after 
infiltration  anaesthesia,  as  the  cutaneous  veins  are  closed  by  the  pressure 
of  the  solution  and  are  consequently  overlooked. 

Subcutaneous  Separation  of  the  Skin. — The  severest  injuries  of  the 
subcutaneous  tissues  are  those  associated  with  a  separation  of  the  skiu 
from  the  subjacent  tissues.  The  skin  may  be  torn  loose  from  the  sub- 
jacent fascia  by  force  acting  obliquely  (in  railroad  and  machine  in- 
juries). Blood  and  lymph  are  then  poured  out  beneath  the  loosened 
skin,  elevating  the  latter  to  form  a  tense,  fluctuating  swelling.  Lacera- 
tion of  the  muscles,  blood  vessels,  and  nerves,  and  injuries  of  the  bone 
may  occur  at  the  same  time.  A  large  hematoma  or  an  extravasation 
of  lymph  forms  in  these  cases,  and  some  of  the  characteristic  signs — 
swelling,  discoloration  of  the  skin,  fluctuation,  and  crepitation — are  • 
rarely  absent. 

The  characteristic  physical  findings  associated  with  an  extensive  sub- 
cutaneous separation  of  the  skin  were  first  described  by  IMorell-Lavallee  • 
under  the  term  of  decollement  de  la  peau,  and  later  by  Koehler.  The 
findings  differ  from  those  associated  with  the  typical  extravasations  of 
blood  described  above.  The  swelling  develops  gradually,  often  several 
days  intervening  before  it  reaches  its  maximum  size,  w^hile  the  swell- 
ing associated  with  a  typical  h^ematoma  develops  rapidly.  The  fluid 
poured  out  beneath  the  separated  skin  is  usually  serum,  although  at 
times  there  may  be  a  small  amount  of  blood.  As  the  lacerated  lym- 
phatic vessels  are  not  closed  by  thrombi,  the  extravasation  continues 
until  the  pressure  of  the  exuded  lymph  equals  the  intravascular  lym- 
phatic pressure.  As  the  latter  is  low  the  swelling  never  presents  the 
resistance  associated  with  haematomas,  but  imparts  a  flaccid,  relaxed 
sensation.  The  shape  of  the  swelling  varies  with  changes  in  the  posi- 
tion of  the  body,  and  a  distinct  wave  of  fluctuation  can  be  elicited  by 
tai)ping  the  swelling  with  the  finger.  The  separation  of  the  skin  asso- 
ciated with  an  accumulation  of  lymph  occurs  most  frequently  upon  the 
thigh;  occasionally  upon  the  trunk  (Fiebiger).  Besides  this  separation 
of  the  skin  (superficial  decollement),  there  also  occurs  a  stripping  of 
the  muscles  and  periosteum  from  the  bone  (deep  decollement). 

The  treatment  of  subcutaneous  separation  of  the  skin  begins  with 
careful  sterilization  of  the  area  involved  and  the  aseptic  dressing  of  all 
excoriations.  A  compression  bandage,  when  properly  applied,  favors 
absorption.  The  skin,  however,  is  deprived  of  a  number  of  its  nutrient 
ai'teries,  and  necrosis  is  ay)t  to  occur  unless -the  dressing  is  applied 
evenly  and  changed  often.     'I'hc  hirger  accumulations  slioidd  be  removed 


MECHANICAL   INJURIES   OF   Till-]    DIFFERENT  TISSUES  523 

by  aspiration  before  the  dressing  is  applied.  Accumulations  of  lymph 
]iiay  be  injected  with  alcohol  or  a  five  per  cent  solution  of  iodin  before 
the  dressing  is  applied.  Incision  is  to  be  recommended  only  when  ne- 
nosis  or  inflammation  is  beginning.  Phlegmons  find  favorable  condi- 
tions for  development  in  these  cases.  Frequently  they  pursue  a  severe 
clinical  course  after  contusions. 

A  complete  separation  of  the  scalp  from  the  subjacent  tissues  has 
been  reported  {vide  Altermatt).  This  accident  occurs  most  frequently 
in  people  who  work  about  machines,  the  hair  being  caught  in  the  belts 
connecting  the  driving  wheels.  The  entire  scalp  may  be  torn  off  and 
the  resulting  defect  must  then  be  skin-grafted.  Separation  of  the  skin 
covering  tlie  penis  and  scrotum  has  also  been  observed  in  accidents  caused 
by  machinery. 

Injuries  of  Mucous  Membranes. — Injuries  of  the  mucous  membranes 
are  quite  similar  to  those  of  the  skin,  except  that  wounds  and  excoria- 
tions of  the  former  are  not  followed  by  such  virulent  infections  as  are 
those  of  the  latter.  However,  a  submucous  haemorrhage  following  a 
gunshot  wound  or  a  subcutaneous  injury  may,  if  the  larynx  is  involved, 
cause  a  laryngeal  stenosis  and  threaten  life.  If  the  stomach  or  intestines 
are  involved  a  fatal  perforative  peritonitis  may  develop,  as  a  result  of 
the  nutritional  disturbances,  ending  in  necrosis  and  perforation,  caused 
by  the  pressure  of  the  blood  clot. 

Traumatic  Emphysema. — Traumatic  emphysema  presents  a  rather 
characteristic  clinical  picture.  It  develops  after  injuries  of  the  air 
passages,  when  the  expired  air  is  forced  into  the  meshes  of  the  loose 
subcutaneous  tissues  and  into  the  cellular  tissues  surrounding  muscles, 
vessels,  and  viscera. 

The  mild  forms,  in  which  the  swelling  is  not  so  marked,  are  asso- 
ciated with  injuries  of  the  nose,  frontal  and  maxillary  sinuses,  and 
mastoid  process.  It  develops  in  injuries  of  the  nose  when  the  pa- 
tient attempts  to  remove  blood  clots  by  blowing.  The  severer  cases 
follow  perforation  of  the  lung  by  a  fractured  rib,  bayonet,  or  pro- 
jectile, injuries  and  inflammatory  (tuberculous)  perforation  of  the 
larynx  and  trachea,  especially  when  the  wound  canal  is  narrow  and 
oblique. 

An  emphysema  may  develop  after  tracheotomy  if  the  air  escapes  by 
too  narrow  an  outlet.  I  have  seen  a  slight  subcutaneous  emphysema 
develop  after  a  laparotomy  performed  in  the  Trendelenburg  position, 
the  air  in  the  abdominal  cavity  being  forced  by  vomiting  or  coughing 
into  the  subcutaneous  tissues  on  either  side  of  the  wound.  Frequently 
emphysema  develops  after  wounds  of  the  soft  tissues,  the  air  having 
been  forced  into  the  tissues  through  a  drain  or  during  irrigation.  An 
emphysema  may  develop  in  wounds  produced  by  blank  cartridges,  the 


524  THE   MECHANICAL   INJURIES 

shot  being  fired  at  very  close  range  and  the  gases  formed  during  the 
explosion  being  driven  into  the  tissues  (Hammer,  Schaefer). 

A  subcutaneous  emphysema  is  characterized  by  development  of  a 
soft,  elastic  swelling  with  indistinct  boundaries  which  has  a  tympanitic 
note,  crackles  when  palpated,  and  is  painless.  This  swelling  may  in-' 
crease  rapidly  in  size,  especially  when  the  patient  is  restless,  and  spread 
over  large  areas.  In  marked  cases  the  emphysema  may  involve  the 
entire  skin,  which  then  becomes  inflated  like  a  balloon  and  transformed 
into  a  tense,  tympanitic,  crackling  mass. 

The  localized  forms  of  emphysema  are  the  most  common.  In  these 
cases  the  emphysema  is  limited  to  a  small  area,  the  swelling  attains  its 
greatest  size  in  a  few  days  and  gradually  subsides  as  the  air  is  absorbed. 

The  greatest  danger  associated  with  the  most  marked  forms  of 
emphysema  is  extension  to  the  mediastinum.  For  example,  a  case  has 
been  observed  in  which  the  infiltrating  air  extended  from  a  wound  of 
the  thorax  over  the  entire  trunk,  neck,  face,  and  extremities,  finally 
beneath  the  pleura^,  and  from  the  loose  connective  tissues  of  the  neck 
into  the  mediastinum.  The  latter  was  already  affected  as  a  result  of 
an  injury  of  the  trachea  and  larynx  before  the  subcutaneous  emphysema 
developed.  The  respiratory  and  cardiac  functions  were  interfered  with 
and  death  followed,  the  symptoms  being  those  of  suffocation. 

Traumatic  emphysema  is  readily  differentiated  from  gas  phlegmon, 
as  in  the  former  all  the  symptoms  of  local  and  general  infection  are 
wanting. 

The  treatment  consists  of  closing  the  wound  from  which  the  air  is 
escaping,  when  possible,  or  of  incising  the  tissue  and  permitting  of  the 
escape  of  air,  thus  preventing  the  infiltration  of  more  tissue.  The  nose 
may  be  closed  with  tampons.  Wounds  of  the  larynx  and  trachea 
should  be  found  and  closed  by  sutures.  Penetrating  wounds  of  the  chest 
associated  with  pneumothorax  should  be  tamponed,  or,  if  this  is  not  suc- 
cessful, the  opening  should  be  enlarged  and  the  opening  in  the  parietal 
pleura  closed.  If  the  latter  is  not  successful  or  the  air  is  discharged 
from  a  lung  which  is  adherent  to  the  chest  wall,  the  wounds  in  the  soft 
tissues  should  ])e  dilated  and  a  drainage  tube,  provided  with  a  valve 
which  ])ermits  of  the  escape  of  air  dui'ing  ex[)iration  (von  Bramann), 
insei-tcd  (Konig).  The  same  pi-oeedurcs  should  be  followed  in  treating 
emphysema  developing  after  injuries  of  the  lungs  caused  by  fractured 
ribs,  when  compression  docs  not  suffice  to  prevent  the  emphysema.  It 
is  often  ])ossible  to  prevent  the  spreading  of  an  emphysema  by  making 
free  incisions  into  the  tissues  ])rininrily   inv()lv(>d   (Konig). 

LrrEKATUiiK. — Altermatt.  Ein  Full  von  totalor  Skalpioruiif^.  Boitr.  z.  klin.  Cliir., 
Bd.  18,  p.  7G5,  18!)7. — v.  lirnmann.  Uebcr  die  Bok;inii)fuiTg  des  na(^h  Lvingciivcrlctzung 
auftretenden  allgemeincn   Korpercmphysems.     Chir.    Kongr.-Verhandl.,    1893.     Disk. 


MECHANICAL    INJURIES   OF   THE    DIFFERENT   TISSUES  525 

Konig. — Cordua.  l^eber  den  Ro«ori)tion.smefhaiiisinus  von  Blutprgiissen.  Preisschrif t . 
Berlin,  1877. — Fiebiger.  Ein  Full  von  subkutaiier  trcumatischer  Lyniphorrhagie. 
Wien.  klin.  Wochenschr.,  1897,  No.  17. — Gussenbauer.  Die  traumatischen  Verletzungen. 
Deutsche  Chir.,  IHSO.— Hammer.  Trauinatisches  Hautemphysem  (lurch  Pulvergase. 
Beitr.  z.  klin.  Chir.,  Bd.  25,  1899. — Jutkowskl.  Ueber  plastische  Operationen  an  Penis 
und  Skrotum  ini  Anschluss  an  einen  P^all  (Kausch)  von  Schindung  der  miinnlichen 
Genitalien.  I.-D.  Breslau,  1904. — Klaussner.  Studie  iiberdas  allgenicine  traumatische 
Eniphysem.  Miinchen,  1886. — Kohler.  Ueber  Morell-Lavallees  DecoUenient  trau- 
niatique  de  la  peau  et  des  couches  sousjacentes.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  29, 
1889. — Madlena.  Das  Hautemphysem  nach  Laparotomien.  Monatsschr.  f.  Geb.  u. 
Gynak.,  Bd.  13,  1902. — Raviant  et  Marlier.  Emphyseme  souscutane  de  la  face,  du 
ecu  et  du  tronc.  Gazette  hebdomad.,  1899,  No.  38. — Schdfer.  Ueber  Hautemphysem 
nach  Schussverletzung.     Beitr.  z.  klin.  Chir.,  Bd.  28,  1900. 


II.     INJURIES  OF  FASCIA  AND   MUSCLES 

(a)  SUBCUTANEOUS   INJURIES 

A  subcutaneous  laceration  of  fascia  may  be  caused  by  the  sudden 
contraction  of  the  muscle  or  muscles  which  it  covers.  The  fascia  of  the 
biceps  brachii  is  ruptured  most  fj-eriuently  when  an  attempt  is  made  to 
prevent  a  heavy  load  from  falling.  The  fascia  of  the  adductors  is  rup- 
tured quite  freciuently  during  horseback  riding,  the  rider  attempting  to 
maintain  himself  in  position  by  contracting  the  adductor  nuiscles  when 
the  horse  suddenly  shies  or  kicks.  Usually  the  fascia  is  lacerated  over 
the  belly  of  the  muscle,  but  occasionally  it  gives  way  at  other  points, 
especially  if  the  fascia  has  been  previously  injured  by  a  fractured  bone. 

Muscle-Hernia. — The  rent  in  the  fascia  may  be  felt,  when  the  muscle 
is  at  rest,  as  an  iri-egular,  oblique  defect  in  which  a  circumscribed  soft 
swelling  (which  increases  in  size  and  becomes  hard  when  the  nuiscle 
contracts)  can  be  palpated.  This  so-called  muscle-hernia  causes  some 
distress  at  first,  but  later  occasions  but  little  or  no  pain,  and  interferes 
but  little  with  the  function  of  tlie  nuiscle. 

Operative  closure  of  the  rent  in  the  fascia  is  therefore  but  rarely 
indicated.  If  indicated,  the  tear  may  be  closed  by  passing  sutures 
through  the  edges  of  the  fascia,  including  also  some  of  the  muscle  fibers, 
thus  securing  a  firm  grasp  of  the  tissues.  At  times,  in  repairing  large 
muscle-hernia\  it  may  be  necessary  to  remove  the  projecting  i)art  of  the 
muscle,  preliminary  to  closing  the  fascia.  Small  rents  in  the  fascia 
demand  no  treatment. 

A  miLscle-hernia  is  often  simulated  by  the  bulging  of  a  circumscribed 
thin  area  in  the  fascia  when  the  nuiscle  contracts. 

Fascial  injuries  due  to  contusions  are  often  associated  with  similar 
injuries  of  the  nuiscles. 

Contusion  of  Muscles. — IMuscular  contusions  are  caused  by  severe  falls 
and  blows.     They  are  especially  apt  to  occur  when  muscles  are  pressed 


526  THE   MECHANICAL   INJURIES 

against  bones.  They  may  also  be  cansecl  by  the  bites  of  animals  (horse- 
bites).  A  slight  contusion  is  merely  followed  by  an  infiltration  of  blood 
into  the  muscle  involved.  In  the  severer  injuries  part  of  the  muscle  is 
destroyed,  considerable  blood  is  poured  out  into  the  wound,  and  a  brown- 
ish red,  pulpified  mass  (muscle  ha^matoma)  is  formed. 

The  injured  muscle  then  no  longer  contracts  normally,  and  when 
attempts  at  contraction  are  made  fibrillary  twitchings  occur.  Disturbed 
function,  severe  pain,  and  swelling,  the  size  of  which  depends  upon  the 
amount  of  hfemorrhage,  are  the  most  important  symptoms  of  a  contusion 
of  a  muscle.  Fluctuation  can  be  distinctly  elicited  only  in  the  large 
hematomas.  There  is  no  discoloration  of  the  skin,  unless  the  fascia  and 
subcutaneous  tissues  are  also  injured. 

The  prognosis  varies.     Frequently  all  the  symptoms  disappear  in  a 
few  weeks.     The  destroyed  muscle  tissue  is  replaced  by  granulation  tis-    ' 
sue,  which  is  soon  transformed  into  a  firm  scar    (myositis  traumatica 
fibrosa).      This  scar  tissue   remains   permanently,   notwithstanding  the    | 
fact  that  after  a  time  a  few  regenerating  muscle  fibers  infiltrate  it.     It    ' 
does  not,  however,  interfere  with  the  function  of  the  muscle,  unless  a 
large  part  of  the  latter  has  been  destroyed.     If  this  has  happened  a 
contracture  which  may  seriously  interfere  with  the  function  of  the  part    ; 
develops.      Ossification    of    a    muscle    (myositis    ossificans    traumatica), 
which  may  follow  a  single  or  repeated  trauma,  and  infection  either 
through  the  lymphatics  or  blood  are  rare  sequela\     Extensive  destruc- 
tion of  a  muscle  is  more  frequently  followed  by  the  formation  of  large 
encapsulated  haimatomas  or  extravasations  of  lymph,  the  tissues  sur- 
rounding which  become  calcified  or  ossified,  than  by  scar  formation. 

These  do  not  interfere  greatly  with  function,  but  are  troublesome 
because  of  their  size  and  weight.  The  symptoms  and  prognosis  of  a 
contusion  involving  the  entire  thickness  of  a  muscle  are  the  same  as 
those  of  a  laceration. 

The  early  treatment  consists  of  massage  and  moderate  compression 
obtained  by  a  properly  applied  bandage.  Massage  should  be  employed 
later,  the  pain  and  swelling  frecfuently  disappearing  and  motion  return- 
ing within  two  weeks  after  it  is  begun.  Trau^matie  blood  and  lymph 
cysts  require  repeated  aspiration.  In  some  cases  a  radical  operation — 
complete  reinoval  of  the  cyst — is  re(iuired.  Contractures  may  be  cor- 
rected by  tenotomy  and  function  improved  by  uniting  detached  ends  of 
muscles  to  adjacent  healthy  tendons  or  muscles,  when  this  procedure  is 
indicated  and  possible. 

Laceration  of  Muscles. — A  laceration  of  a  muscle  may  be  complete,  j  I 
or  ineoiiq)K'te,  and  affect  the  belly  of  the  muscle  or  the  point  of  tran- 
sition of  muscle  fibers  into  the  tendon.     Lacerations  may  be  produced 
in  a  number  of  ways.     They  may  follow  excessive  stretching  of  a  resting 


MECHANICAL   INJURIES   OF   THE   DIFFERENT   TISSUES  527 

muscle;  for  example,  laceration  of  the  steriio-ckido-mastoid  muscle  in 
difficult  breech  presentations,  of  the  adductor  nuiscles  of  the  thigh  in 
forceful  attempts  to  reduce  a  congenital  dislocation  of  the  hip  under 
iuia'sthesia.  In  other  cases  the  muscle  fibers  are  lacerated  when  the  mus- 
cle contracts  powerfully ;  for  example,  when  an  attempt  is  made  to  lift  a 
heavy  weight.  A  muscle  is  much  more  easily  lacerated  in  a  contracting 
than  in  a  resting  state.  The  following  examples  which  almost  always 
occur  in  muscular,  well-built  men  may  be  cited : — Rupture  of  the  rectus 
abdominis  or  the  quadriceps  extensor  in  attempting  to  prevent  a  fall 
backward;  of  the  quadriceps  extensor  or  the  muscles  of  the  calf  in  jump- 
ing from  some  distance  or  in  springing  up  suddenly  from  the  floor. 
Very  frequently  the  biceps  brachii  (most  commonly  the  long  head)  is 
ruptured  in  lifting  a  heavy  weight.  The  nuiscles  about  the  shoulders,  in 
the  neck,  back,  or  abdominal  wall  are  quite  often  lacerated  by  sudden 
overextension  or  torsion  of  the  trunk. 

A  nuiscle  may  also  be  ruptured  by  direct  violence,  but  this  mechan- 
ism is  nuich  rarer  than  that  cited  above.  A  diseased  muscle  (degenera- 
tion associated  with  and  following  such  diseases  as  typhoid  fever,  scarlet 
fever,  smallpox,  general  infections,  acute  miliary  tuberculosis,  etc.)  may 
rupture  even  when  it  is  not  overstretched  or  forcibly  contracted ;  for 
example,  the  rectus  abdominis  may  rupture  at  the  first  attempts  of  a 
convalescent  typhoid  patient  to  walk.  Lacerations  of  nuiscles,  like  con- 
tusions, are  frequently  associated  with  other  injuries,  such  as  fractures 
with  a  wide  displacement  of  fragments  and  dislocations. 

The  symptoms  of  a  rupture  of  a  muscle  are  not  always  distinct. 
Sudden,  lightninglike  pain  in  the  muscle  involved  and  complete  loss  of 
function  are  the  most  positive  symptoms.  Often  the  patient  hears  at 
the  time  of  the  accident,  a  distinct  snap.  If  the  rupture  is  complete  the 
gap  in  the  nniscle  can  be  distinctly  palpated  at  first.  Later  a  ha?matoma 
develops  and  fills  this  in.  When  attempts  at  movement  are  made  both 
ends  of  the  muscle  contract  if  the  innervation  is  still  preserved.  If  the 
rupture  is  incomplete  an  indistinct  swelling  due  to  the  accumulation  of 
blood  which  is  limited  to  the  muscle  develops. 

Repair  as  in  contusions  is  followed  by  the  development  of  scar  tissue. 
If  the  rupture  is  incomplete,  repair  may  be  established  in  one  or  two 
weeks.  When  the  rupture  is  complete  the  ends  of  the  muscle  may  be- 
come united  by  this  scar  tissue  and  the  function  completely  reestablished. 
If  the  development  of  the  sear  tissue  is  excessive,  a  hard  fusiform  swell- 
ing forms.  This  is  the  muscle  callus  which  gradually  contracts  and 
becomes  smaller,  often  producing  deformities.  Wryneck  following  in- 
juries of  the  sterno-cleido-mastoid  muscle  at  birth  is  a  conunon  example. 

The  treatment  of  an  incomplete  rupture  of  a  muscle  is  the  same  as 
that  of  a  contusion.     If  the  rupture  is  complete  an  attempt  should  be 


528  THE   MECHANICAL   INJURIES 

made  to  approximate  the  two  ends  by  immobilizing  the  parts  in  the 
proper  position.  The  plaster-of-Paris  dressing  which  is  applied  for  this 
purpose  should  be  allowed  to  remain  from  four  to  six  weeks.  Suturing 
of  the  ends  of  the  ruptured  nuisele  is  a  much  more  certain  procedure 
than  the  (me  just  mentioned,  and  should  always  be  advised  when  the 
space  between  the  divided  ends  is  great.  It  should  not  be  delayed  too 
long.  The  immobilizing  dressing  applied  after  suturing  should  be 
allowed  to  remain  for  three  weeks.  If  muscle  suture  is  delayed  the  rup- 
tured ends  retract  and  atrophy,  and  can  no  longer  be  brought  together. 
Transplantation  of  muscle  is  rarely  successful  in  these  cases,  for  the  tis- 
sue rapidly  degenerates  and  is  of  no  value  in  filling  in  the  defect. 
Massage  and  active  motion  are  important  in  the  after-treatment. 

(b)  OPEN    INJURIES    OF    FASCIA   AND    MUSCLES 

Depending  upon  the  character  of  the  vulnerating  force  these  wounds 
are  either  incised,  lacerated,  or  contused. 

The  results  depend  upon  the  amount  of  functional  disturbance  and 
the  development  of  inflammation.  The  functional  disturbances  follow- 
ing punctured  and  gunshot  wounds,  superficial  incised  wounds,  and  con- 
tusions are  slight  and  transitory,  unless  there  is  an  injury  of  some  motor 
nerve.  On  the  other  hand,  the  results  following  injuries  produced  by  a 
hatchet,  a  saber,  a  bayonet  or  knife,  the  explosion  of  a  bomb,  or  inflicted 
by  some  animal  are  severe  and  permanent  unless  proper  treatment  is 
instituted.  Infection  develops  in  a  miLscle  wound  with  frayed  edges 
very  easily,  while  clean-cut  wounds  are  inclined  to  heal  by  primary 
union.  The  small  wound  of  entrance  associated  wdth  punctured  and 
gunshot  wounds  favor  healing  without  infection. 

The  treatment  usually  does  not  differ  from  that  of  a  simple  wound. 
Fascia  and  muscle  Avhich  have  been  divided  should  be  sutured.  Buried 
catgut  or  silk  sutures  should  be  employed,  and  the  divided  ends  of  the 
muscles  should  be  accurately  approximated,  so  that  no  dead  spaces  are 
left.  After  the  muscle  is  sutured,  the  fascia  should  be  united  with  some 
superficial  sutures.  The  scar  which  follows  healing  by  primary  union 
is  insignificant,  and  almost  coinplctely  disappears  after  a  short  time.  If 
the  wound  is  not  very  recent  it  is  a  good  plan  not  to  close  the  skin 
completely,  but  to  insert  a  tampon  of  iodoform  gauze  which  extends 
to  the  line  of  suture,  and  can  be  replaced  by  a  tubular  drain  if  infection 
occurs.  In  recent  contused  and  lacerated  wounds  and  in  compound  frac- 
tures the  divided  muscles  should  be  sutured  after  the  severely  injured 
muscle  tissue  has  been  removed.  If  the  wound  is  not  recent,  it  should 
be  left  open  and  allowed  to  heal  by  granulation  tissue.  If  the  func- 
tional disturbance  following  contraction  of  the  scar  is  great  the  results 
may  be  improved  by  a  plaslic  opci-ation  ui)()ii  the  muscle.  h 


MECHANICAL    INJURIES   OF   Till']    DIFFERENT  TISSUES  529 

Literature. — Fire.  Les  accidents  de  I'attaqiie  d'epilepsie  lies  a  la  contraction 
musculaire.  Revue  de  Chirurgie,  T.  21,  1900,  p.  M. — Loos.  Ueber  subkutane  Biceps- 
rupturen.  Beitr.  z.  kiln.  Chir.,  Bd.  29,  1901,  p.  410. — Murchand.  Der  Prozess  der 
Wuntlheilung.  Deutsche  Chir.,  1901.  Heihmg  tier  Muskelwunden,  y>.  289. — Maydl. 
Subkutane  Muskel-  und  Sehnenzerreissungen.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  17. — 
Steudel.  Zur  Behandlung  und  Operation  der  Muskelbriiche.  Beitr.  z.  klin.  Chir.,  Bd. 
Si,  1902,  p.  611. 

III.     INJURIES   OF  TENDON 
(a)  SUBCUTANEOUS    INJURIES 

Contusions  of  tendon.s  occur  only  when  great  force  is  applied  (ma- 
chine injuries,  kicks  by  horses,  etc.).  Tendons  are  very  resistant  to 
the  milder  forms  of  trauma,  and  as  they  frequently  lie  upon  soft  tissue, 
they  are  pushed  aside  and  escape  injury  when  the  vulnerating  force 
acts.  Crushed  tendons  are  frayed  and  fibrillated.  If  the  tendon  lies  in 
a  tendon  sheath,  an  extravasation  of  blood  may  occur  in  the  latter,  when 
the  corresponding  tendon  is  contused  or  lacerated  by  the  contraction 
of  the  nuiscle  to  which  it  is  attached,  or  by  the  powerful  contraction 
of  an  antagonistic  muscle.  These  injuries  are  frequently  associated  with 
fractures  and  dislocations. 

Rupture  of  Tendons. — Rupture  of  a  tendon  occurs  less  frequently 
than  the  corresponding  injury  of  a  muscle.  In  rupture  of  a  tendon 
the  solution  of  continuity  takes  place  more  frequently  at  the  point  of 
insertion  of  the  tendon  into  the  bone  and  at  the  junction  of  the  muscle 
with  the  tendon  than  in  the  tendon  proper.  If  rupture  occurs  at  the 
point  of  attachment  of  the  tendon  to  the  bone,  a  piece  of  the  latter  is 
usually  torn  otf ,  and  the  tendon  is  frayed  at  the  point  of  rupture. 

Tendons  are  usually  ruptured  by  the  rapid  contraction  of  powerful 
nuiscles;  less  frequently  by  direct  force  acting  when  the  muscle  is  at 
rest.  Trauma,  direct  or  indirect,  associated  with  a  dislocation  may  be 
the  direct  etiological  factor  in  the  rupture  of  a  tendon.  Long-continued 
inrtnmmation  and  repeated  mechanical  insults  (von  Volkmann's  fragil- 
itas  tendinum)  may  be  predisposing  factors.  Softening  of  the  tendons 
combined  with  fibrillation  which  is  associated  with  certain  occupations 
(e.  g.,  changes  in  the  extensor  longus  pollicis  of  the  left  hand  of  drum- 
mers and  the  development  of  a  ganglion)  may  favor  rupture  of  the  ten- 
don or  tendons  involved. 

Tendons  Most  Frequently  Ruptured. — The  tendons  of  the  quadriceps 
extensor  and  of  the  biceps  brachii  are  ruptured  most  frequently.  The 
ligamentum  patellte  may  be  ruptured  at  its  point  of  attachment  to 
the  tibia  or  to  the  patella.  Fibers  of  the  quadriceps  extensor  tendon 
may  be  ruptured  at  their  points  of  attachment  to  the  patella  or  to 
the  muscle.  In  rare  cases  the  tendinous  tissue  is  ruptured  both  above 
and  below  the  patella.     The  long  head  of  the  biceps  may  be  ruptured 


530  THE   MECHANICAL   INJURIES 

at  its  middle  or  torn  away  from  its  point  of  attachment  to  the  scapida. 
The  tendo  Achillis  may  be  torn  aAvay  from  its  point  of  attachment  to 
the  OS  calcis;  the  tendon  of  the  triceps  from  its  point  of  attachment  to 
the  olecranon  process.  The  attachments  of  the  extensor  tendons  of  the 
fingers  to  the  terminal  phalanges  are  occasionally  torn  loose  when  the 
distal  phalanges  are  forcibly  flexed  and  the  two  proximal  phalanges 
remain  extended.  The  attachments  of  the  superficial  and  deep  flexor 
tendons  of  the  fingers  may  be  torn  away  with  pieces  of  the  bones  by  a 
sudden  powerful  contraction  of  the  extensors  when  the  fingers  are 
fiexed. 

Symptoms. — The  rupture  of  a  tendon  is  frequently  indicated  by  a 
sharp  audible  snap  which  is  accompanied  by  pain.  Loss  of  the  func- 
tion of  the  muscle  involved ;  a  change  in  the  position  of  the  extremity  or 
part  of  the  extremity  (e.  g.,  flexion  of  the  terminal  phalanx  following 
rupture  of  the  attachment  of  the  extensor  tendon)  ;  loss  of  resistance 
between  the  ends  of  the  tendon,  or  between  the  tendon  and  the  bone,  as 
the  case  may  be;  and  displacement  of  the  distal  end  of  the  belly  of  the 
muscle  in  a  direction  opposite  to  the  one  which  it  normally  passes  when 
contraction  occurs  are  the  most  important  signs  of  a  rupture  of  a 
tendon.  As  a  rule,  the  hematoma  which  develops  after  such  an  injury 
is  not  very  large. 

If  a  tendon  is  ruptured  an  operation  should  be  performed  as  soon  as 
possible,  and  the  defect  in  the  tendon,  between  the  tendon  and  bone, 
or  between  the  tendon  and  the  muscle  repaired  by  suture.  The  ex- 
tremity should  then  be  placed  in  an  immobilizing  dressing  to  prevent 
contraction  of  the  muscles.  The  part  should  be  placed  in  a  position 
which  relaxes  the  muscles  when  the  dressing  is  api)lied.  Immobilization 
should  be  continued  from  four  to  six  weeks.  The  distal  end  of  the  long 
head  of  the  biceps  may  be  sutured  to  the  short  head  if  the  ruptured 
ends  have  retracted  so  much  that  approximation  is  impossible.  If  the 
ends  of  ruptured  tendons  have  retracted  so  much  that  it  is  impossible 
to  unite  them,  a  tenoplasty  should  be  performed.  Frequently  the  scar 
which  develops  between  the  sutured  ends  of  a  tendon  stretches,  and  the 
function  of  the  muscle  is  permanently  impaired,  unless  another  opera- 
tion is  performed,  the  scar  tissue  is  removed  and  the  vivified  ends  of 
the  tendon  are  sutured  again. 

Subluxation  of  Tendons. — By  subluxation  of  a  tendon  is  understood 
a  cliange  in  the  position  of  a  tendon  following  rupture  of  its  synovial 
sheath  and  restraining  bands.  Subluxation  of  tendons  is  rare.  It  occurs 
most  fre(iuently  al)out  the  external  malleolus,  tlve  tendon  of  the  peroneus 
longus  or  tlu;  t<'ndons  of  both  i)eronei  muscles  being  displaced  forward 
after  rupture  of  their  synovial  sheaths  and  restraining  bands.  The 
ri'tinaciiln   ;in(l   slicalhs  ace  most  fre(|uently  torn   in  the  latter  case  by 


MECHANICAL   IXJl'RIES   OF   THE   DIFFERENT  TISSUES  531 

sudden  t'tiiit Taction  of  the  peronei  imiscles  Avlien  the  foot  is  in  the  X'Osi- 
tion  of  supination.  Sul)hixation  of  the  tendon  of  the  tibialis  posticus 
has  been  observed  but  once.  Subluxation  of  the  long  head  of  the  biceps 
may  occur  after  rupture  of  its  sheath,  together  with  the  capsule  of  the 
joint  and  the  attachment  of  the  supraspinatus  muscle.  This  occurs  only 
with  fractures  of  the  neck  of  the  humerus  or  dislocations  of  the  shoulder 
(Konig).  Subluxation  of  the  extensor  tendons  of  the  fingers  to  the  ulnar 
side  of  the  heads  of  the  metatarsal  bones,  after  rupture  of  the  bands 
passing  from  the  radial  side  of  the  dislocated  to  the  adjoining  tendon, 
has  been  occasionally  observed  ( Schuermayer,  Haberern,  Becker).  A 
similar  subluxation  of  the  tendons  may  occur  in  chronic  articular  rheu- 
matism. The  extensor  tendons  may  then  be  displaced  so  far  forward 
that  they  might  act  as  flexors  instead  of  extensors  (Krukenberg). 

Diagnosis  and  Treatment. — The  displaced  tendon  may  easily  be  felt 
in  its  abnormal  position,  and  easily  returned  to  the  position  which  it 
should  occupy.  If  it  is  possible  to  hold  the  tendon  in  its  proper  posi- 
tion for  a  number  of  weeks  by  a  gauze  or  cotton  pad  over  which  an 
immobilizing  dressing  is  applied,  healing  in  normal  position  may  occur. 
If  the  function  of  the  part  is  interfered  with  and  conservative  treat- 
ment has  been  unsuccessful,  an  operation  should  be  performed.  If  the 
old  sheath  can  be  found,  the  tendon  should  be  replaced  and  the  margins 
of  the  sheath  sutured  over  it.  If  the  sheath  cannot  be  found  a  new 
canal  should  be  made  out  of  the  surrounding  connective  tissues,  the 
tendon  placed  in  it,  and  the  connective  tissues  sutured  over  it,  forming 
a  substitute  for  the  normal  restraining  bands.  Flaps  of  fascia,  or, 
according  to  Konig,  a  periosteal-osteal  flap  when  the  tendons  of  the 
peronei  nniscles  are  dislocated,  may  be  used  for  this  purpose, 

(b)  OPEN   INJURIES   OF   TENDONS 

Wounds  associated  with  partial  or  complete  division  of  tendons  occur 
most  frequently  on  the  hands.  They  are  less  common  on  the  feet  and 
other  parts  of  the  body.  These  injuries  are  usually  produced  by  sliarp 
instruments  or  objects,  such  as  knives,  pieces  of  metal  and  glass,  or  are 
associated  with  contusions  and  lacerations  caused  by  machinery,  the 
explosion  of  shells  or  boilers,  and  by  the  bites  of  animals.  They  are 
often  associated  with  wounds  of  vessels,  nerves,  bones,  and  joints,  or 
with  more  extensive  wounds,  the  injury  of  the  tendons  then  being  of 
secondary  importance.  The  ends  of  the  tendons  are  clean  cut,  contused, 
or  fibrillated,  depending  upon  the  character  of  the  wound.  The  entire 
tendon,  even  up  to  its  origin  from  the  muscles,  may  be  torn  away  in  the 
severer  injuries  caused  by  machinery. 

The  divided  ends  cannot  always  be  seen  in  the  wound,  even  after 
it  has  been  carefully  cleaned,  and  its  margins  held  apart  with  hook 


532  THE   MECHANICAL   INJURIES 

retractors.  They  retract  from  the  wound,  the  proximal  end  naturally 
retracting  the  most.  Those  tendons  with  long  synovial  sheaths  and 
the  greatest  range  of  motion  retract  the  most.  The  distal  end  retracts 
less  than  the  proximal.  Even  when  a  flexor  tendon  is  injured  when  the 
part  is  in  flexion  and  is  subsequently  extended,  the  distal  retracts  less 
than  the  proximal  end. 

Diagnosis. — If  a  division  of  a  tendon  is  suspected,  the  function  of 
that  tendon  should  be  tested.  Tliis  should  always  be  done  in  injuries 
adjacent  to  a  tendon,  even  if  the  wound  is  very  small. 

Treatment. — An  attempt  should  always  be  made  to  perform  a  pri- 
mary tendon  suture  in  wounds  of  this  character,  unless  the  injury  to 
the  tendon  or  the  character  of  the  wound  contraindicates  such  a  pro- 
cedure. Severely  contused  and  frayed  tendons,  such  as  are  frequently 
associated  with  contused  and  lacerated  wounds,  are  not  at  all  suited  for 
primary  suture  as  necrosis  occurs,  and  besides  the  resistance  of  the 
tissues  is  so  reduced  that  infection  is  apt  to  occur.  It  is  often  better 
in  these  cases  to  delay  suturing  until  the  conditions  are  more  favorable 
for  repair.  It  is  even  dangerous  to  search  for  and  to  suture  the  ends 
of  tendons  in  wounds  which  have  been  improperly  treated  or  neglected, 
and  in  which  suppuration  has  already  developed.  Suppuration  is  fol- 
lowed by  necrosis  at  the  line  of  suture  and  by  changes  in  the  tendon 
5  heaths,  which  may  be  followed,  if  the  flexor  tendons  of  the  fingers  are 
involved,  by  a  progressive  phlegmon  extending  rapidly  to  the  fascial 
spaces  of  the  forearm  or  by  contractures. 

If  the  wound  is  not  clean  or  cannot  be  properly  prepared,  primary 
tendon  suture  should  not  be  performed.  The  wound  should  be  treated 
by  the  open  method  until  healthy  granulation  tissue  has  developed  or 
the  wound  has  healed.  Then  a  secondary  tendon  suture  should  be  per- 
formed as  soon  as  possibl(\  In  these  cases  it  is  always  difficult  to  find 
the  proximal  eiuls  of  the  tendons  as  they  have  retracted,  and  the  space 
between  the  divided  ends  is  often  so  great  that  it  is  impossible  to 
unite  them. 

Incomplete  division  of  a  tendon  is  difficult  to  recognize,  as  there  is 
no  loss  of  function.  The  defect  is  usually  easily  recognized,  however, 
when  llie  wound  is  being  treat(^d. 

Tendon  Suture. — The  part  should  be  rendered  bloodless  before  an 
attempt  is  made  to  find  the  ends  of  the  tendons,  Avhich  are  more  readily 
found  in  recent  than  in  old  wounds  in  which  considerable  scar  tissue 
has  already  formed.  The  distal  ends  may  l)e  found  by  hy]^erflexion  or 
hyperextension  of  the  pai-t,  as  the  case  may  be,  while  the  proximal 
ends  may  be  made  to  a])pear  by  bandaging  or  massaging  the  belly  of 
the  nniscle  involved  toward  the  wound.  In  cases  in  which  the  ends 
have  retracted   a  great  deal,  it  may  l)e  necessary  and   advantageous  to 


MECHANICAL   INJURIES  OF  THE   DIFFERENT  TISSUES 


533 


incise  the  tendon  sheath  in  both  the  proximal  and  distal  directions. 
The  incision  should  be  made  to  one  side  of  the  tendon  in  order  to 
prevent  union  between  the  two  layers  of  the  synovial  membrane.  In 
okl  cases  it  may  be  necessary  to  make  a  rather  extensive  dissection 
in  order  to  find  the  ends  of  the  tendons.  The  scar  tissue  should  be 
removed. 

The  ends  of  the  tendons  should  be  anchored  by  a  silk  suture  as  they 
are  found.  This  suture  should  be  applied  so  that  it  can  be  used  later 
in  uniting  the  divided  ends.  If  a  number  of  tendons  have  been  divided, 
as  frequently  happens  in  cuts  involving  the  flexor  surface  of  the  wrist, 
it  may  be  difficult  to  identify  the  ends  which  should  be  united.  The 
appearance,  position  and  size,  anatomical  relations,  and  function  of  the 
divided  ends  indicated  when  traction  is  made  upon  them  all  aid  in 
recognition  of  the  separate  ends. 

The  ends  of  crushed  and  lacerated  tendons  should  be  resected  before 
they  are  united. 

When  the  other  end  is  found,  the  suture  which  has  already  been 
inserted  in  the  end  previously  found  should  be  passed  through  the 
former.  The  suture  should  then  be  tied,  the  muscle  to  which  the  tendon 
is  attached  being  held  in  a  relaxed  position  in  order  to  prevent  the 
sutures  cutting  out.  The  ends  nnist  be  accurately 
coapted;  a  side-to-side  approximation  avoided. 

Sublimate  silk  should  be  used  in  suturing  tendons. 
A  number  of  different  methods  of  tendon  suturing 
have  been  devised.  The  sim- 
plest are  the  best.  I  employ 
the  method  devised  by  Fried- 
rich  (Fig.  213)  in  suturing 
small  tendons,  that  devised  by 
Ilaegler  (Fig.  214,  h)  in  sutur- 
ing large  ones.  The  sutures 
recommended  by  Woelfler  and 
Trnka  are  more  complicated. 

The  tendon  sheaths,  if  opened 
by  the  vulnerating  force  or  in- 
cised in  searching  for  the  ten- 
dons, should  be  closed  over  the 
tendons  with  fine  catgut  or  silk 
sutures.  Bands  which  retain  the  tendons  in  position,  such  as  tlie  an- 
terior and  posterior  annular  ligaments  and  the  vincula,  should  ho  care- 
fully sutured. 

When  a  number  of  t(>ndons  have  been  sutured,  adhesions  may  form 
between  at  the  points  of  suture.    Lotheisen  has  recommended  that  each 


Fig.  213. — Tendon  Suture  Acconnixr.  to  Fried- 
rich.  The  first  suture  (a)  is  gras])0(l  by  the 
second  suture  (b)  which  is  passed  parallel  to  the 
long  axis  of  the  tendon.  After  both  sutures 
are  applied  the  suture  (a)  is  tied  and  then  the 
suture  (6).  (Von  Bergmann's  "  Haiulbook  of 
Practical  Surgery.") 


534 


THE   MECHANICAL   INJURIES 


tendon  be  surrounded,  after  suture  has  been  performed,  by  a  sterilized 
gelatin  tube  in  order  to  prevent  these  adhesions.  [A  flap  of  fat  may  be 
dissected  upon  and  placed  around  the  tendon  when  the  wound  is  closed. 
Adhesions  may  be  prevented  in  this  way.] 

The  wound  in  the  skin  should  then  be  sutured,  an  opening  being  left 
for  drainage.     Drainage  should  not  be  made  directly  over  the  tendons, 

as  adhesions  may  then  form 
between  the  tendons  and  the 
skin.  If  infection  occurs, 
several  sutures  should  be  re- 
moved and  iodoform  gauze 
inserted.  If  a  phlegmon  de- 
velops all  the  skin  sutures 
should  be  removed.  It  may 
then  even  be  necessary  to 
remove  the  sutures  in  the 
tendon  sheaths. 

After  the  ends  have  been 
united,  the  joint  should  be 
immobilized  in  such  a  posi- 
tion that  there  is  no  traction 
upon  the  sutures.  If  the 
tendons  are  small,  innnobil- 
ization  should  be  continued 
for  about  four  weeks;  if 
large — for  example,  as  large 
as  the  tendo  Achillis  and 
the  ligamentum  patellae — it 
should  be  continued  for  at 
least  six  weeks. 

Active  and  passive  mo- 
tions should  be  jierformed 
very  cautiously  when  begun, 
as  the  new  tissue  which  is 
formed  in  the  repair  of  ten- 
dons is  fragile.  AVarm  baths  and  massage  of  the  muscles  involved  are 
of  great  value.  If  the  wound  heals  by  ])riniary  unicm,  a  good  result 
can  usually  be  obtained  after  two  or  three  months. 

Tendons  are  repaii-ed  by  the  foi-mation  of  scar  tissue.  This  tissue 
is  foi'iiicd  by  1li('  ])i'()lif(M-a1i()n  of  the  cells  of  the  tendons  and  tendon 
shcallis,  and  by  those  oC  tlic  surrounding  connective  tissue.  These  cells 
infiltrate  the  blood  clot  which  foi'ms  b''twe('n  the  divided  ends  of  the 
tendons,  and  eventually  beconie  transfoi^med  into  tissue  which  cannot 


d 

Fig.  214. — a,  Tendon  Suture  according  to  Woelf- 
ler;  h.  According  to  Haegler  (after  the  First 
Suture  which  is  Passed  at  Right  Angles  to  the 
Long  Axis  of  the  Tendon  is  Tied,  it  is  Grasped 
BY  Two  Sutures  Passed  Parallel  to  the  Long 
Axis  of  the  Tendon)  ;  c-/,  According  to  Trnka. 


MECHANICAL   INJURIES  OF   THE   DIFFERENT  TISSUES 


535 


be  differentiated  after  three  months  from  that  composing  the  tendons 
(Lit.  by  ]\Iarehand.  Seg-gel). 

Tenoplasty  and  Tendon  Transplantation. — Two  operative  procedures 
— tenoplasty  and  tendon  transplantation — may  be  employed  to  repair 
or  overcome  extensive  defects  in  tendons.  These  procedures  may  also 
be  used  to  correct  contractures  and 
overcome  functional  defects  associated 
with  paralysis.  ,•• 

a  b 


^    1 


111 


Fig.  215. — a,  Hueter  Method,  Single  Flap; 
h,  Glijck's  Method,  Catgut  Repair. 


Fig.  216. — Single-flap  Method. 


["  Tenoplasty  (tendon  lengthening)  may  be  utilized  to  remedy  de- 
formities due  to  otherwise  irremediable  shortening  of  tendons  dependent 
on  contraction  and  sloughing,  which  are  often  the  sequel  of  traumatism 
and  inflammation. 

"  A  tendon  may  be  lengthened  by  a  single  flap  (Figs.  215,  a,  216) 
or  it  may  require  for  the  purpose  the  union  of  double  flaps,  one  from 
the  end  of  each  extremity  (Fig.  217). 


Fig.  217. — Double-flap  Method. 

"  The  making  of  alternate  free  incisions  at  the  borders  of  a  tendon 
(the  accordion  plan)  so  as  to  cause  the  tendon  to  assume  an  accordion 
appearance  when  lengthened  (Fig.  218)  is  much  more  ingenious  than 
practical.  Less  pronounced  cutting  (Fig.  219)  followed  by  tendon 
lengthening  is  called  the  incision  method  (Fig.  220)," — Bryant's  "  Op- 
erative Surgery,"  Vol.  I,  p.  341.] 


536 


THE   MECHANICAL   INJURIES 


The  transplantation  of  tendons  was  first  attempted  by  Nieoladoni. 
It  has  been  perfected  by  von  Drobnik,  Vnlpius,  Iloft'a,  and  Lange. 

The  purpose  of  this  operation  is  to  transfer  a  part  of  the  proximal  end 
of  a  healthy  muscle  to  the  tendon  of  a  paralyzed  muscle  or  to  the  point 
of  attachment  of  the  latter.  The  flap  taken  from  the  healthy  muscle 
naturally  maintains  its  connection  with  it.     This  operation  is  intended 

to  correct  functional  dis- 
turbances following  inju- 
ries or  diseases  of  tendons, 
those  peculiar  to  muscular 
atrophy,  and  diseases  of 
muscles  and  nerves. 


Fig.  218.  Fig.  219.  Fig.  220. 

Fig.   218. — A.  Poncet's  Accordion  Method. 

Fig.  219. — Incision  Method. 

Fig.  220. — Tendon  Lengthened  in  Incision  Method. 


Fig.  221.- — Lengthening  of  Ten- 
dons. In  A  the  peripheral 
end  of  the  defective,  paralyzed 
or  cut  tendon  is  sutured  into 
the  side  of  a  healthy  ailjacent 
tendon,  while  in  B  a  flap  is 
prepared  from  the  healthy  fen- 
don  into  which  the  peripiuM'al 
stumji  of  the  diseased  tendon  is 
sutured. 


Fig.  221).     For  example, 


In  this  operation  the  distal  end  of  the 
defective  or  paralyzed  tendon  which  has 
been  previously  divided  or  vivified  is  su- 
tured to  the  side  of  the  tendon  of  a  healthy 
muscle  or  to  a  flap  taken  from  the  tendon 
llie  distal  end  of  a  divided  flexor  or  extensor  tendon  of  a  finger  may 
])e  sutured  to  one  of  the  adjacent  tendons  which  is  intact. 

Periosteal  tendon  transplantation  is  a  modification  of  the  preceding 
method.  The  distal  end  of  the  paralyzed  tendon  is  not  utilized,  but  a 
tendon,  the  function  of  which  can  be  spared,  or  a  flap  from  an  adjacent 
tendon,  is  attached  to  the  periosteum  at  the  point  normally  occupied  by 
the   paralyzed  one.     The  flap  or  the  tendon  which  is  tran.splanted  is 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  537 

passed  beneath  the  fascia,  a  restraining  band  thus  being  formed  for  it. 
As  in  tenoplasty,  a  bridge  of  silk  or  of  strands  of  catgut  can  be  used 
to  fill  in  the  defect  between  the  tendon  and  its  periosteal  attachment. 

An  immobilizing  dressing  of  plaster-of-Paris  must  be  applied  after 
tendon  transplantaticm,  the  part  beijig  inunobilized  in  a  position  in  which 
the  afit'ected  tendons  are  relaxed.  Immol)ilization  should  be  continued 
for  from  five  to  seven  weeks,  after  which  time  careful  active  and  pas- 
sive motion  may  be  instituted. 

Literature. — Becker.  Beitrage  zu  den  traumatischen,  nicht  komplizierten  Luxa- 
tionen  der  Extensorensehnen  der  Finger.  Miinch.  med.  Wochenschr.,  1903,  No.  12. — 
Blauel.  LTeber  die  Naht  bei  subkutaner  Zerreissung  des  Lig.  patellae. — Beitr.  z.  klin. 
Chir.,  Bd.  29,  1901. — Borst.  Ueber  die  Heilungsvorgange  nach  Sehnenplastik.  Ziegler's 
Beitr.  z.  pathol.  Anat.,  Bd.  34,  1903. — Friedrich.  Subkutane  Zerreissungen  der  Sehnen 
an  Hand  und  Fingern.  Handb.  d.  prakt.  Chir.,  IV.  Bd.,  2.  Aufl.,  p.  300. — Haherern. 
Ueber  Sehnenkixationen.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  62,  1902,  p.  192. — Hiigler. 
Ueber  Sehnenverletzungen  an  Hand  und  Vorderarm.  Beitr.  z.  klin.  Chir.,  Bd.  16,  1896. 
Kirchmayr.  Zur  Kasuistik  der  subkutanen  Sehnenrupturen.  "Wien.  klin.  Wochenschr., 
1900,  No.  45. — Krukenberg.  Lehrbuch  der  mechanischen  Heilmethoden.  Stuttgart, 
1S96,  pp.  72,  73. — Kiittner.  Ueber  subkutane  Sehnenscheidenhiimatome.  Beitr.  z. 
klin.  Chir.,  Bd.  44,  1904,  p.  213. — Lange.  Weitere  Erfahrungen  liber  seidene  Sehnen. 
Miinch.  med.  Wochenschr.,  1902,  No.  1. — Lessing.  Traumatische  subkutane  Ruptur 
einer  Fingerbeugersehne  in  ihrer  Kontinuitat.  Beitr.  z.  klin.  Chir.,  Bd.  30,  1901. — 
Lotheisen.  Zur  Technik  der  Sehnen-  und  Nervennaht.  Arch.  f.  klin.  Chir.,  Bd. 
64,  1901;— Ueber  die  Zerreissungen  im  Streckapparate  des  Kniegelenkes.  Beitr. 
z.  klin.  Chir.,  Bd.  24,  1899,  p.  673. — Marchaml.  Der  Prozess  der  Wundheilung.  Deutsche 
Chir.,  1901,  Heilung  der  Sehnenwunden,  p.  261. — Schiirmayer.  Luxation  iler  Streck- 
sehne  des  Mittelfingers.  Zeitschr.  f.  Chir.,  1897,  p.  846. — Seggel.  Histologische  Unter- 
suchungen  iiber  die  Heilung  von  Sehnenwunden  und  Sehnendefekten.  Beitr.  z.  klin. 
Chir.,  Bd.  37,  p.  342,  1903. — Witzel.  Ueber  Sehnenverletzung  und  ihre  Behandlung. 
v.  Volkmann's  Samml.  klin.  Vortrage,  No.  291,  1887. 


IV.     INJURIES   OF   TENDON    SHEATHS   AND   BURSiE 

Blood  may  be  extravasated  into  tendon  sheaths  and  burstv  after  con- 
tusions and  lacerations.  A  tense,  frequently  fluctuating,  painful,  cir- 
cumscribed swelling  which  corresponds  in  position  and  size  to  the  sheath 
or  bursa  involved  then  develops.  The  pain  is  increased  when  attempts 
at  movement  are  made.  Usually  all  the  symptoms  subside  after  a  few 
weeks  if  the  part  is  kept  quiet  and  a  bandage  exerting  mild  compression 
is  applied. 

If  the  case  is  neglected  a  chronic  inflammation  develops  and  a  hy- 
groma forms.  A  similar  condition  is  produced  by  foreign  bodies  if 
lodged  in  a  tendon  sheath  or  bursa  and  by  repeated  traumatism. 

Open  injuries  of  tendon  sheaths  and  bursa^  are  very  apt  to  be  com- 
plicated by  infection.  If  infection  does  develop  in  a  tendon  sheath,  it 
may  extend  very  rapidly  to  neighboring  structures. 


538   -  THE   MECHANICAL   INJURIES 

Aseptic  treatment  of  the  wounds  and  early  incision  of  inflammatory 
foci  are  the  indications  to  be  met  in  the  treatment  of  these  cases. 


V.     INJURIES  OF  PERIPHERAL   NERVES 

Injuries  of  peripheral  nerves  may  so  interfere  with  or  destroy  their 
power  of  conduction  that  their  function  (transmission  of  sensory,  motor, 
reflex,  vasomotor,  and  trophic  impulses)  may  be  more  or  less  completely 
interfered  with.  The  degree  of  the  functional  disturbance  depends  for 
the  most  part  upon  the  extent  of  the  changes  in  the  nerve  fibers.  Slight 
transitory  disturbances  follow  destruction  of  the  medullary  sheaths; 
severe  and  permanent  ones,  injury  and  degeneration  of  the  axis  cylinders. 

(a)  SUBCUTANEOUS   INJURIES 

The  most  connnon  subcutaneous  injuries  are  concussions,  contusions, 
lacerations,  and  subluxations.  A  concussion  may  affect  a  nerve  trunk 
(for  example,  concussion  of  the  ulnar  nerve  caused  by  a  blow  on  the 
elbow)  or  all  of  its  terminal  fibers  of  distribution  (for  example,  con- 
cussion associated  with  a  fall,  the  patient  alighting  on  the  hands  or  feet). 
The  transitory  functional  disturbances  accompanied  by  pain  disappear 
after  a  few  minutes.  A  severe  concussion  of  sensory  nerves  may  produce 
the  clinical  picture  of  shock. 

Contusion  of  Nerves. — Pressure  palsy  represents  the  mildest  form  of 
a  nerve  contusion.  It  frequently  occurs  when  the  upper  or  lower  ex- 
tremity is  held  in  an  improper  position  during  sleep,  the  radial,  ulnar, 
and  sciatic  nerves  being  most  frequently  involved.  A  sensation  of  numb- 
ness is  first  experienced.  When  the  position  of  the  limb  is  changed  a 
tingling  sensation  is  experienced  for  a  short  time,  and  then  the  normal 
conditions  are  rapidly  restored.  A  paralysis  which  may  last  for  several 
weeks  may  occur  during  anaesthesia  if  the  arm  is  allowed  to  hang  over 
the  edge  of  the  table  and  pressure  is  exerted  upon  the  musculospiral 
nerve,  or  when  the  arm  is  elevated  and  abducted  and  the  head  of  the 
huiiierus  is  pressed  against  the  brachial  plexus.  Contusion  of  the  sciatic 
nerve,  followed  by  paralysis,  is  occasionally  caused  by  attempts  at  reduc- 
tion of  ti-aumalic  and  congenital  dislocations  of  the  hip.  An  Esmarch 
constrictor  improperly  applied  or  allowed  to  remain  for  too  long  a  time 
may  produce  a  long-standing  or  permanent  paralysis,  the  radial,  ulnar, 
and  external  popliteal  nerves  being  most  frecjucMitly  injured  in  this  way. 
Pressure  exerted  by  callns  is  not  an  infj'e(|uent  cause  of  an  injury  of  this 
type.  Nerves  which  are  closely  applied  to  bone,  such  as  the  musculo- 
spiral in  the  arm,  the  ulnar  behind  the  internal  epicondyle,  and  the 
external  popliteal  as  it  winds  about  llic  licnd  of  the  fil)ula,  are  the  ones 
inost  connnonly  affected.     A  comi)lete  ]);irii]ysis  which   is  preceded  by 


MECHANICAL    INJURIES   OF   THE   DIFFERENT   TISSUES      "     539 

sensory  disturbances  and  neuralgic  pains  develops,  unless  the  nerve 
involved  is  dissected  out  of  the  callus.  The  same  symptoms  are  pro- 
duced when  a  nerve  is  imbedded  in  a  mass  of  scar  tissue,  when  it  is 
pressed  upon  by  a  projecting  fragment  of  a  bone,  or  displaced  and  infil- 
trated by  a  new  growth. 

A  sudden  mild  contusion  may  produce  much  the  same  clinical  pic- 
ture as  a  concussion,  but  a  severe  injury  produced  by  blunt  force,  such 
as  is  associated  with  a  blow  or  fall  or  is  experienced  when  a  fragment 
of  a  fractured  bone  is  driven  into  the  soft  tissues,  may  be  accompanied 
by  marked  functional  disturbances.  These  may  subside  if  conditions 
favorable  for  repair  are  provided,  or  may  grow  worse  and  become 
permanent  if  improperly  treated. 

Stretching  and  Laceration  of  Nerves. — Stretching  and  laceration  of  a 
nerve  may  be  followed  by  transitory  or  permanent  changes.  Paralysis 
of  the  nerves  of  the  arm  may  follow  a  dislocation  of  the  shoulder. 
Disturbances  of  vision,  loss  of  sensation,  and  paralysis  of  one  half 
of  the  face  may  be  caused  by  laceration  or  contusion  of  the  optic, 
trigeminal,  and  facial  nerves  respectively  in  fractures  of  the  base  of 
the  skull. 

The  recognition  of  nerve  injuries  of  this  type,  as  well  as  of 
those  associated  with  open  injuries,  is  usually  based  upon  impair- 
ment of  function  of  the  nerves  involved  and  upon  the  location  of  the 
wound. 

Injuries  of  muscles,  ischa^mic  palsies  and  contractures  following  in- 
juries and  inflammatory  processes  in  the  extremities  may  cause  some 
difficult}^  in  making  a  diagnosis.  They  are  differentiated  from  nerve 
injuries  by  the  absence  of  disturbances  of  sensation  and  of  the  reaction 
of  degeneration. 

The  amount  of  restoration  of  function  depends  upon  the  extent  of 
injury  to  the  nerves,  upon  their  ability  to  regenerate,  and  upon  whether 
conditions  favorable  for  regeneration  are  provided. 

The  treatment  of  simple  subcutaneous  contusions  and  lacerations  of 
nerves  should  be  conservative.  During  the  first  week  the  part  involved 
should  be  immobilized  in  a  cast,  in  order  to  prevent  any  added  injury 
to  the  nerves  by  movements.  When  electrical  treatment  is  instituted 
later,  the  weak  galvajiic  current  should  be  employed,  if  there  is  a  reac- 
tion of  degeneration.  The  cathode  should  be  placed  over  the  seat  of 
injury,  the  anode  over  the  plexus  (Oppenheim). 

A  complete  division  of  the  nerve  can  be  excluded  if  the  loss  of 
function  is  only  partial.  Complete  restitution  of  function  occurs 
after  a  few  weeks  in  these  cases  if  a  conservative  line  of  treatment 
is  followed.  If  the  injury  apparently  involves  the  eiitiic  diameter 
of  the   nerve   and  no   results   followed   electrical   treatment   continued 


540  THE   MECHANICAL   INJURIES 

from  four  to  six  weeks,  operative  interference  should  no  longer  be 
delaj-ed.  After  this  time  but  little  can  be  expected  of  conservative 
treatment,  and  if  the  operation  is  delayed  the  prognosis  becomes  bad. 
When  the  nerve  is  exposed  it  is  usually  found  imbedded  in  a  mass 
of  scar  tissue.  If  the  nerve  is  completely  severed,  its  ends  are 
separated  by  it.  After  the  ends  of  the  nerve  have  been  dissected 
free,  they  should  be  vivified  or  resected  and  sutured  or  united  by 
neuroplasty. 

If  the  paralysis  is  clue  to  the  inclusion  of  the  nerve  in  a  callus  or  a 
mass  of  scar  tissue,  it  should  be  dissected  out  of  the  mass  enclosing  it 
(neurolysis).  In  order  to  prevent  pressure  from  scar  tissue  developing 
after  neurolysis,  the  nerve  should  be  surrounded  by  a  flap  of  muscle  or 
by  one  made  from  the  surrounding  fatty  tissues.  If  the  electrical  con- 
ductivity of  the  nerve  has  not  been  lost,  its  function  is  usually  restored 
within  a  few  days.  Even  when  there  is  doubt  as  to  the  condition  of  a 
nerve,  neurolysis  should  first  be  tried,  and  then  if  there  is  no  return 
of  function  after  a  number  of  weeks,  the  injured  area  should  be  resected 
and  the  ends  sutured  (Schecle). 

Subluxation  of  Nerves, — The  ulnar  and  external  popliteal  nerves  are 
about  the  only  ones  that  are  ever  displaced.  Displacements  of  these 
nerves  are  most  often  associated  with  fractures  of  the  medial  epicondyle 
of  the  humerus  and  of  the  head  of  the  fibula.  If  the  medial  epicondyle 
is  very  small  and  flat  and  the  ulnar  nerve  is  not  firmly  fixed  in  its 
groove,  it  may  be  displaced  by  sudden  forcible  flexion  of  the  forearm. 
An  habitual  displacement  which  may  be  either  congenital  or  traumatic 
may  even  occur.  In  such  a  case  the  nerve  is  partially  or  completely 
displaced  with  every  attempt  at  flexion  of  the  forearm  and  when  the 
triceps  muscle  contracts  forcibly,  but  the  patient  experiences  no  pain 
or  disturbance  of  function   (IMomburg). 

Symptoms,  as  a  rule,  develop  only  when  the  displacement  is  due  to 
traumatism.  They  are  then  due  to  a  contusion  or  inflammation  of  the 
nerve.  A  positive  diagnosis  can  be  made  of  the  nature  of  the  lesion 
by  pain  which  radiates  throughout  the  entire  distribution  of  the  nerve, 
by  sensory  and  motor  disturbances,  and  by  finding  the  painful  nerve  in 
an  abnormal  position. 

If  there  are  no  functional  disturl)ances  associated  with  the  displace- 
jiient,  treatment  is  not  necessary.  If  the  displaced  nerve  is  painful  or 
its  function  is  interfered  with,  it  should  be  dissected  free,  replaced  in 
its  normal  position,  and  maintained  there  by  suturing  a  flap  of  fascia 
or  muscle  over  it  (IMomburg).  If  the  ulnar  nerve  is  but  recently  dis- 
placed, an  at1<'iiipt  should  be  ituide  to  reduce  it  without  an  operation. 
If  the  a1tciii|)t  is  successful,  the  roi'canii  should  J)e  iniiiiobilized  in  the 
extended  position  until  repair  is  completed. 


MECHANICAL   INJURIES   OF  THE   DIFFERENT  TISSUES  541 

(b)  OPEN    INJURIES   OF    NERVES 

In  open  wounds  nerves  may  be  partially  or  completely  cut  across, 
pierced,  shot  through,  crushed,  or  lacerated.  Crushing  and  lacerating 
injuries  of  nerves  are  most  frequently  associated  with  complicated  frac- 
tures, the  displaced  fragments  of  bone  injuring  the  nerves.  Fragments 
of  bone,  likewise  foreign  bodies  (pieces  of  glass,  wood,  and  metal,  bul- 
lets and  fragments  of  shells)  may  become  lodged  in  a  nerve  and  sur- 
rounded by  a  dense  connective  tissue.  This  scar  tissue  gradually  con- 
tracts until  the  function  of  the  nerve,  which  was  at  first  merely  impaired, 
is  completely  destroyed.  Occasionally  a  ligature  is  applied  to  a  nerve 
by  mistake,  marked  functional  disturbances  developing  as  a  result. 
Large  segments  of  nerves  may  be  torn  away  in  injuries  associated  with 
explosions  of  boilers  and  shells,  in  machinery  accidents,  and  in  bites 
inflicted  by  wild  animals. 

The  divided  ends  of  a  nerve  retract  but  little  unless  they  are  dis- 
placed by  fragments  of  bone  or  lacerated  muscles.  The  cut  surface 
never  appears  smooth  as  the  nerve  bundles  project  beyond  it.  A  con- 
tused area  may  be  recognized  directly  after  the  injury  by  its  red  color 
and  soft  consistency. 

Degeneration  of  Divided  Nerves. — Degeneration  follows  the  separa- 
tion of  nerve  fibers;  it  makes  no  difference  whether  they  are  cut  across, 
lacerated,  or  contused.  A  limited  traumatic  degeneration  occurs  very 
soon  at  the  point  of  injury.  Tliis  is  followed  in  from  two  to  four  days 
by  the  secondary  (paralytic)  degeneration  Miiich  extends  to  all  that 
part  of  the  nerve  distal  to  the  point  of  injury,  and  also  involves  a 
small  segment  immediately  proximal  to  the  wound.  Therefore  a  direct 
union  of  the  nerve  ends  with  restitution  of  function  (the  so-called  prima 
intentio  nervonon)  is  an  impossibility  even  when  the  connections  be- 
tween the  nerve  fillers  are  retained  or  the  cut  surfaces  are  immediately 
approximated  and  sutured.  Degeneration  of  injured  nerves  always 
occurs.  It  is  the  primary  process  which  ends  in  the  regeneration  of 
fibers  and  the  repair  of  nerves. 

Regeneration  of  Nerves. — The  beginning  of  regenerative  changes  is 
indicated  as  early  as  the  second  day  by  enlargement  of  the  nuclei  of  the 
cells  of  the  sheath  of  Schwann  and  numerous  karyokinetic  figures.  De- 
generation of  the  medullary  sheath  is  indicated  by  the  accunndation  of 
fragments,  balls,  and  granules  of  myelin;  of  the  axis  cylinders  by  fibril- 
lation. The  formation  of  new  axis  cylinders  and  medullary  sheaths  is 
apparently  associated  with  the  regenerative  changes  in  the  cells  of  the 
sheath  of  Schwann  (von  Buengner,  P.  Ziegler,  Wieting,  Marchand). 
There  is,  however,  no  uniformity  of  opinion  among  investigators  as  to 
the  role  played  by  the  sheath  cells  in  the  regeneration  of  nerves,  many 


542  THE  MECHANICAL  INJURIES 

(Ranvier,  Vanlair,  von  Nottliaft,  Strocbe)  believiii>i'  that  new  axis  cylin- 
ders are  formed  only  by  outgrowths  from  preexisting  ones. 

The  new  nerve  fibers  are  first  found  in  the  proximal  end  of  the 
divided  nerve.  They  are  connected  with  the  old  fibers.  In  favorable 
cases  these  new  fibers  infiltrate  the  grannlation  tissue  which  is  formed 
from  the  sheath  cells  and  bridges  over  the  space  between  the  divided 
ends.  These  newly  formed  fibers  then  gradually  grow  into  the  distal 
segment  of  the  nerve  even  to  its  terminal  filaments.  Waller,  Vanlair, 
Stroebe,  and  others  believe  that  this  so-called  neurotization  is  the  method 
by  which  nerves  regenerate.  Von  Buengner,  Wieting,  and  Kennedy 
believe  that  the  fibers  which  develop  in  the  proximal  end  form  a  direct 
union  with  incompletely  differentiated  elements  in  the  distal  segment, 
and  that  the  latter  go  on  to  complete  differentiation  only  after  this 
union  is  complete. 

Conditions  Favoring  and  Retarding  Regeneration. — Absence  of  wound 
infection,  incomplete  division  of  a  nerve  (or  after  complete  division 
accurate  approximation  of  the  cut  ends),  and  very  limited  injuries, 
such  as  might  be  produced  by  tying  a  ligature  about  a  nerve,  are  the 
conditions  which  favor  most  complete  repair. 

Repair  may  be  retarded  or  prevented  if  an  infection  develops,  if  a 
large  amount  of  scar  tissue  develops  between  the  divided  ends,  if  a 
large  segment  of  the  nerve  is  destroyed,  or  if,  after  complete  division, 
muscle,  bone,  or  a  foreign  body  becomes  interposed  between  the  ends  or 
the  latter  are  displaced  and  remain  out  of  line. 

If  any  of  these  conditions  are  present  the  proximal  end  becomes  bul- 
bous (amputation  neuroma),  while  connective  tissue  develops  in  the 
distal  portion  of  the  nerve,  which  gradually  decreases  in  size  following 
the  absorption  of  the  fragmented  myelin. 

Secondary  Changes  in  Muscles. — The  muscles  supplied  by  the  injured 
nerve  eventually  undergo  complete  atrophy  (neurogenous  muscular 
atrophy). 

]\lotor  and  mixed  nerves  have  but  little  regenerative  power,  and  it 
cannot  be  definitely  said  that  repair  will  always  follow  even  when  favor- 
able conditions  are  provided.  This  is  so,  notwithstanding  the  fact  that 
it  has  been  demonstrated  by  animal  experiments  that  defects  several 
centimeters  in  length  may  heal  spontaneously  (Tiedemann),  or  after 
bridging  over  the  space  between  the  divided  ends  by  using  decalcified 
bone  tubules  (Vanlair),  sterilized  segments  of  arteries  (von  Buengner)  ; 
strands  of  catgut  (Gluck,  Assaky),  pieces  of  nerves  from  other  animals 
(Gluck),  and  that  spontaneous  union  (e.  g.,  after  laceration  of  the 
brachial  plexus  by  a  fragment  of  a  bomb,  Langenbeck)  and  union  after 
the  use  of  the  devices  mentioned  above  have  also  occurred  in  man.  Re- 
generation  occurs   much   more   frequently   and   completely   in   sensory 


MECHANICAL   INJURIES  OF  THE   DIFFERENT  TISSUES  543 

nerves,  as  the  return  of  neuralgic  pains  after  extensive  removal  of  the 
branches  of  the  trigeminal  nerve  and  the  restoration  of  sensation  in  the 
skin  of  the  neck  after  the  radical  removal  of  tuberculous  lymph  nodes 
indicate. 

Symptoms. — The  symptoms  of  a  nerve  injury  are  indicated  l)y  loss 
of  function  and  develop  immediately.  The  symptoms  depend  upon  the 
function  of  the  nerves,  and  after  injury  of  mixed  nerves,  which  are 
most  frequently  affected,  they  are  both  sensory  and  motor.  Eventually 
vasomotor  and  trophic  disturbances  are  also  noted.  Pain  and  panes- 
thesia  are  most  commonly  associated  w^ith  incomplete  division  of  sensory 
and  mixed  nerves. 

Diagnosis. — The  diagnosis  is  based  upon  the  anatomical  position  of 
the  wound  or  scar,  and  upon  the  presence  of  motor  and  sensory  dis- 
turbances. 

The  motor  symptoms  consist  of  a  flaccid  paralysis,  absence  of  or 
impaired  reflexes,  rapidly  developing  muscular  atrophy,  and  loss  of 
function  of  the  nniscles  supplied  by  the  injured  nerves.  The  disturb- 
ances of  function  following  the  injuries  of  nerves  such  as  the  musculo- 
spiral,  ulnar,  external  popliteal,  facial,  etc.,  are  very  characteristic. 
The  diagnosis  may  be  quite  difficult  if  but  a  single  muscle  is  affected 
as  a  result  of  an  injury  to  a  nerve  or  plexus,  as  the  loss  of  function 
may  be  compensated  by  synergists. 

Reaction  of  Degeneration. — The  electrical  reaction  of  the  nerves  and 
the  nniscles  supplied  by  them  should  be  determined  in  all  cases  in  which 
an  injury  to  a  nerve  is  suspected.  The  reaction  of  a  divided  nerve  to 
faradic  and  galvanic  stimulation  gradually  decreases  in  intensity  and 
rapidity,  disappearing  com.pletely  after  twelve  days.  The  reaction  of 
muscles  supplied  by  the  divided  nerves  to  the  faradic  current  disap- 
pears in  the  same  way.  Within  two  weeks,  however,  the  reaction  of 
the  degenerating  muscle  to  the  galvanic  current  is  intensified,  and  the 
reaction  of  degeneration  develops — the  A.C.C.  being  greater  than  the 
C.C.C.  This  reaction  becomes  most  marked  in  from  three  to  four 
weeks,  and  then  persists  for  months.  Sometimes  this  increased  irrita- 
bility to  the  galvanic  current  does  not  disappear  until  after  a  year, 
when  the  atrophy  of  the  muscles  is  complete. 

When  degeneration  occurs  the  antagonistic  muscles  gradually  con- 
tract, producing  deformities.  Contractures  of  the  different  parts  are 
produced  in  this  way. 

Sensory  Disturbances. — The  sensory  disturbances  following  injuries 
of  sensory  and  mixed  nerves  do  not  extend  over  the  entire  area  sup- 
plied by  the  nerves  involved.  The  terminal  filaments  of  these  nerves 
usually  anastomose  freely,  so  that  nerves  supplying  adjacent  cutaneous 
areas  are  united  (e.  g.,  anastomoses  between  the  musculocutaneous  and 


544  THE   MECHANICAL    INJURIES 

median  nerves),  and  besides  there  is  an  overlapping  of  the  cutaneous 
fields,  many  nerves  sending  branches  into  the  same  area.  As  a  result 
of  these  peculiarities  in  the  distribution  of  sensory  and  mixed  nerves, 
the  sensory  disturbances  are  usually  limited  to  a  small  area  which  gradu- 
ally decreases  in  size  even  when  there  is  no  regeneration  of  the  injured 
nerves,  for  filaments  grow  into  the  area  from  branches  of  adjacent 
nerves.  Permanent  and  extensive  sensory  disturbances  occur  only  after 
injury  of  many  adjacent  nerves  or  of  all  the  cords  of  a  plexus  (KoUiker, 
Oppenheim,  Schede) . 

Vasomotor  and  Trophic  Disturbances. — Vasomotor  disturbances  are 
indicated  by  redness,  cyanosis,  and  a  lowering  of  the  temperature  of 
the  skin. 

Trophic  disturbances  affect  usually  the  skin  and  its  appendages.  The 
skin  becomes  glossy  and  smooth ;  there  is  a  tendency  to  eczema.  Herpes 
zoster  and  ulcers  develop  and  the  parts  become  atrophic.  The  bones 
may  become  atrophic  and  growth  may  be  retarded.  Sometimes  a  serous 
exudate  which  is  transitory  and  is  followed  by  stiffness  is  poured  out 
into  the  joints. 

Special  symptoms  follow  division  of  the  sympathetic,  vagus,  phrenic, 
and  cranial  nerves.  These  are  most  often  injured  in  gunshot  and  stab 
wounds  of  the  neck  and  head,  or  during  operations.  The  symptoms 
and  results  of  injuries  of  these  nerves  are  discussed  in  special  surgeries. 

Neuralgia  and  chronic  neuritis  should  also  be  mentioned  as  some  of 
the  remote  results  of  nerve  injuries.  Neuralgia  not  infrequently  de- 
velops when  a  nerve  has  been  exposed  to  pressure  or  repeated  traumas, 
when  it  has  been  partially  severed,  contains  a  foreign  body,  or  when, 
after  regeneration,  it  becomes  so  attached  to  surrounding  tissues  by  a 
scar  that  it  is  pulled  upon  whenever  a  movement  is  attempted.  Neu- 
ritis may  develop  if  infection  occurs  in  an  open  wound  or  if  a  foreign 
body  or  an  infiannnatory  exudate  is  situated  close  to  a  nerve.  Neuritis 
rarely  develops  after  a  simple  contusion. 

Treatment. — In  recent  cases  of  injuries  to  nerves  associated  with 
open  wounds  the  treatment  should  be  operative.  The  w(mnd  and  the 
area  suri-ounding  it  should  be  carefully  sterilized,  a  constrictor  applied, 
and  an  attempt  made  to  find  the  ends  of  the  divided  nerve.  When 
found  they  .should  be  carefully  approximated  by  sutures.  Primary 
nerve  suture  should  also  be  attempted  in  large  contused  and  lacerated 
wounds,  unless  the  defect  in  the  nerve  is  so  great  as  to  render  it 
iinpossible.  A  conservative  expectant  treatment  is  to  be  recommended 
only  after  gunshot  wounds,  especially  after  wounds  caused  by  small 
projectiles.  TTsually  in  llicsi^  cases  tlie  nerve  is  not  completely  divided, 
its  conductivity  being  nierely  interfered  with  for  a  short  time,  and 
recovery  occurs  spontaneously.     If,  in  cases  of  this  character,  there  is 


MECHANICAL   INJURIES  OF   THE   DIFFERENT  TISSUES  545 

no  improvement  of  function  after  several  weeks,  the  nerve  should  be 
exposed  at  the  seat  of  injury,  the  scar  tissue  removed,  the  vivified  ends 
of  the  nerve  sutured,  and  foreign  bodies  which  are  frequently  present 
removed.     This  is  called  secondary  nerve  suture. 

Nerve  Suture. — In  performing  nerve  suture  in  old  cases,  the  divided 
ends  should  first  be  vivified;  the  lacerated,  contused  ends,  or  central 
end,  which'  may  have  become  transformed  into  a  neuroma,  being  re- 
moved with  a  sharp  knife  and  converted  into  a  smooth  surface. 

Scissors  should  not  be  used  to  vivify  the  ends  as  they  crush  the 
fibers.  The  vivified  ends  should  then  be  approximated,  the  most  care- 
ful asepsis  being  practiced,  and  tension  upon  the  ends  being  avoided. 
It  is  advisable  to  employ  the  so-called  direct  suture,  some  fine  cat- 
gut sutures  being  passed  through  the  ends  of  the  nerve.  In  suturing 
small  nerves  it  may  be  necessary  to  pass  the  suture  through  the  entire 
thickness  of  the  nerve  involved.  In  suturing  larger  nerves  the  sutures 
should  grasp  merely  the  outer  part  of  the  nerve  trunk,  avoiding  in  this 
way  injury  of  any  great  number  of  fibers.  A  round,  non-cutting  needle 
should  be  used.  In  the  indirect  nerve  suture  recommended  by  Hueter, 
injury  of  the  nerve  fibers  is  entirely  avoided,  but  an  accurate  approxi- 
mation of  the  ends  not  secured.  In  this  method  only  the  paraneural 
connective  tissues  are  grasped  in  the  sutures.  It  is  advisable  to  com- 
bine both  the  direct  and  indirect  methods  (Tillmanns).  This  is  the 
method  of  nerve  suture  emploj-ed  in  the  von  Bergmann  clinic.  In  su- 
turing very  delicate  nerves  it  is  often  necessary  to  employ  the  para- 
neural suture  alone.  Some .  of  the  other  procedures  which  have  been 
employed  in  uniting  nerves  should  be  mentioned.  In  order  to  avoid 
adhesions  between  the  line  of  suture  and  surrounding  tissues,  which 
often  cause  neuralgia  and  marked  functional  disturbances,  Payr  has 
reconnnended  that  the  suture  line  be  protected  by  a  magnesium  tu1)e. 
Lotheisen  recommends  that  the  nerve  be  imbedded  in  a  gelatin  tubule 
hardened  in  formalin.  Foramitti  recommends  that  a  segment  of  an 
artery  or  vein  taken  from  a  calf  and  thoroughly  sterilized  be  used  for 
the  same  purpose.  The  magnesium  tube  is  first  passed  over  the  end 
of  the  nerve,  and  after  the  suturing  is  completed  it  is  slipped  over  the 
suture  line.  The  gelatin  tubule  or  the  segment  of  an  artery  or  vein 
may  be  split  and  placed  over  the  nerve  after  the  suturing  is  completed. 
These  procedures  are  now  used  instead  of  the  one  devised  by  Vanlair, 
in  which  a  decalcified  piece  of  bone  was  used  to  bridge  over  the  defect. 

Von  Bruns  has  recommended  in  secondary  suture  that  a  longitudi- 
nal incision  be  made  in  the  scar  tissue  uniting  the  ends  and  that  this 
incision  should  then  be  sutured  transversely,  hoping  in  this  way  to 
npproximate  the  ends  of  the  nerve  fibers  (Fig.  222).  When  tliere  is 
no  bridge  of  scar  tissue,  he  has  reconnnended  that  a  V-shaped  piece 


546 


THE   MECHANICAL   INJURIES 


should  be  cut  out  of  the  bulbous  central  end,  and  that  the  distal  end 
should  be  sutured  into  it  after  it  has  been  given  the  proper  shape 
(Fig.  223). 

It  is  especially  difficult  to  unite  divided  ends  of  nerves  when  there 
is  a  v.ide  interval  between  them  resulting  from  a  laceration  or  contusion 


Fig.  222. — Secondary  Nerve  Suture  according  to 
VON  Bruns.  a.  Longitudinal  incision  in  the  scar 
in  the  nerve,  which  in  (6)  is  sutured  transversely. 


Fig.  223.^ — Suture  of  the  Pointed 
Peripheral  End  of  the  Nerve 
into  the  Proximal  End. 


of  a  long  segment,  from  the  resection  of  a  mass  of  scar  tissue  or  the 
removal  of  a  tumor. 

Even  when  there  is  quite  a  defect  nerve  suture  should  be  attempted, 
as  it  is  the  most  reliable  procedure.  Small  defects  up  to  3  cm.  in  length 
can  be  repaired  without  tension  by  cautiously  drawing  the  ends  to- 
gether. Greater  defects,  even  up  to  8  cm.  in  length,  in  some  of  the 
larger  nerves  (radial,  median,  sciatic,  and  popliteal)  may  be  repaired 
by  placing  the  joint  in  extreme  tiexicm,  exteusicm,  or  other  position  de- 
manded by  the  case,  and  by  maintaining  it  in  this  position  for  a  number 
of  weelvs.  AVhen  union  is  probably  very  well  established  the  part  should 
gradually  be  returned  to  its  normal  position.  If  a  long  segment  of  a 
nerve  has  been  destroyed,  a  piece  of  bone  may  be  resected,  an  actual 
shortening  of  the  ])art  being  ])r()duced  in  the  way  which  perniits  of 
api)r<)xiiiiation  of  the  ends  of  the  nerve  (von  Bergmann,  Loebker,  and 
others). 

Neuroplasty  and  nerve  grafting  are  not  as  reliable  as  nerve  suture. 
They  iriay  be  employed  Avhen  the  latter  is  technically  impossible. 

Neuroplasty  and  Nerve  Grafting. — By  neuroplasty,  a  procedure  first 
employed  by  Letievant,  is  understood  the  i'e])air  of  defects  in  nerves 
by  the  use  of  flaps,  the  latter  being  made  from  the  proximal,  distal,  or 
holli  ends  of  the  divided  nerve.  Th(>  bridginti,-  over  of  a  defect  by  a 
(la|)  made   fi-om   Ihe  divi(h'd  ends,  which  ai'e  united  by  sutui'cs,  may  be 


MECHANICAL  INJURIES  OF  THE   DIFFERENT  TISSUES  547 

followed  by  a  eoin'plete  restoi-ation  of  fniietion  ('rilliiuimis).  Other 
methods  in  whieh  the  defeet  is  filled  in  with  some  foreign  material, 
which  acts  as  a  tunnel  or  sealt'olding  for  the  developing  fibers,  are 
also  successful.  Decalcified  tubules  of  bone  (Vanlair's  tubulization), 
strands  of  catgut  (Gluck,  Assaky),  and  segments  of  nerves  taken  from 
other  animals  (Gluck,  Landerer)  have  been  used  for  this  purpose. 

The  procedure  known  as  nerve  grafting  was  also  devised  by  Letie- 
vant.  In  this  method  the  distal  end  of  the  injured  or  paralyzed  nerve 
is  sutured  to  some  adjacent  uninjured  nerve.  The  distal  end  of  the 
injured  nerve  may  be  sutured  to  the  side  of  the  uninjured  nerve,  which 
has  been  vivified  or,  as  has  been  suggested  by  Depres,  into  a  slit  which 
is  made  in  the  latter.  The  attachment  of  the  distal  end  to  the  side  of 
the  uninjured,  even  when  the  latter  has  not  been  vivified,  is  sometimes 
successful  (Manasse).  [No  definite  results  can  be  expected  unless  the 
nerve  is  vivified  and  the  last-mentioned  method  should  not  be  em- 
ployed.] The  distal  end  of  an  extensively  lacerated  median  nerve  has 
been  successfully  united  with  the  ulnar  (Depres).  The  following  suc- 
cessful cases  of  nerve  grafting  may  be  mentioned :  Grafting  of  the  distal 
end  of  the  ulnar  to  the  median;  of  the  distal  end  of  the  injured  mus- 
culospiral  to  a  flap  made  from  the  median  (Sick)  ;  of  the  distal  end 
of  the  paralyzed  facial  to  the  spinal  accessory  (Faure  and  Furat, 
Ilackenbruch,  Gushing,  Ballance  and  Stewart),  or  to  the  hypoglossal 
(Koerte,  Frazier). 

Care  of  the  Cutaneous  Wound  and  Dressing. — When  a  secondary  nerve 
suture  is  performed  the  woinid  in  the  skin  can  always  be  closed  by  a 
plastic  operation  or  by  skin  grafting.  In  primary  suture  the  wound 
should  not  be  closed  unless  the  conditions  are  favorable  for  repair.  If 
the  wound  must  be  left  open,  the  nerve  should  be  surrounded  with  a 
flap  of  muscle  or  fat  in  order  to  prevent  the  scar  from  pressing  upon  it. 

After  the  wound  is  dressed,  the  part  should  be  immobilized  in  a 
splint  or  plaster-of-Paris  dressing  in  a  position  which  permits  of  no 
tension  upon  the  sutured  ends.  Immobilization  should  be  continued 
from  three  to  four  weeks.  When  the  immobilizing  dressing  is  removed, 
the  return  of  function  may  be  hastened  by  electricity,  massage,  active 
and  passive  motion. 

Restoration  of  sensation  is  the  first  indication  that  a  nerve  suture 
has  been  successful.  This,  however,  may  be  deceiving,  as  the  return 
of  sensation  may  be  due  to  the  overlapping  of  cutaneous  sensory  fields 
or  to  the  growth  of  filaments  from  adjacent  nerves.  Then  the  reaction 
of  degeneration  disappears,  the  changes  incited  by  the  galvanic  and 
faradie  currents  approaching  the  normal.  The  return  of  motion  is  first 
indicated  by  muscular  twitching  when  an  attempt  is  made  to  throw  the 
muscle  into  action;  later  by  fairly  powerful  contractions. 


548  THE  MECHANICAL   INJURIES 

Time  Required  for  the  Restoration  of  Function. — The  time  required 
for  complete  return  of  fimetion  diit'ers.  Function  is  usually  reestab- 
lished more  quickly  after  primary  than  after  secondary  nerve  suture 
as  the  muscular  atrophy  which  occurs  when  the  divided  ends  are  not 
sutured  early  becomes  so  extensive  that  muscular  activity  is  restored 
slowly.  The  nearer  the  periphery  the  point  of  suture  the  more  quickly 
regeneration  occurs  (Etzold).  A  long  time  is  required  after  neuroplasty 
for  complete  restoration  of  function. 

Sensation  may  return  in  from  two  to  four  weeks  if  a  nerve  suture 
is  successful.  A  longer  time  is  required  for  the  return  of  motion.  It 
never  returns  earlier  than  three  weeks ;  usually  in  about  six  weeks ;  a 
3'ear  or  more  may  pass  before  motion  returns. 

Results  of  Nerve  Suture. —  [The  results  of  nerve  suture  are  flatteringly 
exhibited  in  the  following  table  (Bowlby)  : 


Primary  suture .  . 
Secondary  suture. 


Successful 

Improved 

Failure 

Total 

32 

34 

14 

80 

32 

26 

15 

73 

These  statistics  would  seem  to  indicate  that  the  results  following 
secondary  suture  are  about  as  good  as  those  following  primary  suture, 
— Bryant's  "  Operative  Surgery,"  Vol.  I,  p.  274.]  A  nerve  suture 
may  be  successful  even  when  undertaken  a  number  of  years  after  the 
nerve  was  divided.  Tillaux  successfully  sutured  the  median  nerve  ■ 
fourteen  years  after  division. 

If  the  suture  is  not  successful,  the  nerve  should  be  exposed  at  the 
point  of  union,  and  the  scar  tissue,  which  is  often  to  blame  for  the  fail- 
ure, dissected  away.  If  the  ends  have  become  separated  by  scar  tissue, 
the  latter  should  be  removed  and  the  vivified  ends  again  sutured. 

Literature. — Ballnnce  and  Stewart.  On  the  Operative  Treatment  of  Chronic  Facial 
Paralysis  of  Peripheral  Origin.  British  Medical  Journal,  1903.  Hildebrands  Jahresber., 
1903. — Cushing.  The  Surgical  Treatment  of  Facial  Paralysis  by  Nerve  Anastomosis. 
Annals  of  Surgery,  1903.  Hildebrantls  Jahresber.,  1903. — Dumstrey.  Ueber  Xerven- 
pfropfung.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  62,  1902,  p.  40. — Etzold.  LTeber  Nervennaht. 
Ebenda,  Bd.  29,  1889,  p.  iSO.—Foramitti.  Zur  Technik  der  Nervennaht.  Arch.  f.  klin. 
Chir.,  Bd.  73,  1904. — -Frazier  and  Spiller.  The  Surgical  Treatment  of  Facial  Paralysis. 
Univ.  of  Pennsylvania  Med.  Bulletin,  1903. — Hildebrands  Jahresber.,  1903.— G/eiss 
(v.  Bruns).  Bcitrage  zur  Nervennaht.  Beitr.  z.  klin.  Chir.,  Bd.  10,  1893,  p.  387.— 
Hackenbruch.  Zur  Behandlung  der  Gesichtslahnumg  thu-ch  Nervenpfropfung.  Chir. 
Kongr.-Verhaiull.,  1903,  II,  p.  231. — Hairn.  Ueber  Luxation  des  Ulnaris.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  74,  1904,  p.  96. — Th.  Kolliker.  Die  Verletzungen  und  chirur- 
gischen  Erkrankungen  der  peripheren  Nerven.  Deutsche  Chir.,  1890. — Korte.  Ein 
Fall  von  Nervenpfropfung  des  N.  facialis  auf  den  N.  hyperglossus.  Deutsche  med. 
Wochenschr.,  1903,  No.  17. — Kramer.  Zur  Neurolyse  und  Nervennaht.  Beitr.  z. 
klin.  Chir.,  Btl.  28,  1900,  p.  423. — Lotheisen.  Zur  Technik  der  Nerven-  und  Sehnennaht. 
Arch.  f.  klin.  Chir.,  Bd.  64,  1901,  p.  310. — Marchand.     Der  Prozess  der  Wundheilung. 


MECHANICAL    INJURIES   OF   THE    DIFFERENT  TISSUES  549 

Deutsche  Chir.,  1901,  Ileilung  der  Nervenwunden,  p.  335. — Momhurg.  Die  Luxation 
des  N.  ulnaris.  Arch.  f.  khn.  Chir.,  Bd.  70,  1903. — Oppetiheim.  Lehrbuch  der  Nerven- 
krankheiten,  Berl'm.—Payr.  Zur  Technik  der  Blutgefass-  und  Nervennaht  (Mag- 
nesiumprothese).  Chir.  Kongr.-Verhandl.,  1900,  II,  p.  593. — Riethus.  Ueber  Verletz- 
ungen  des  N.  radiahs  bei  Humerusfrakturen  und  ihre  operative  Behandhing.  Beitr.  z. 
klin.  Chir.,  Bd.  24,  1899,  p.  703. — Schede.  Chirurgie  der  peripheren  Nerven  und  des 
Riickenmarks.  Handb.  der  spez.  Therapie  der  inneren  Krankheiten  von  Penzoldt  und 
Stintzing,  1898. — Schutte.  Die  Degeneration  und  Regeneration  peripherer  Nerven 
nach  Verletzungen.  Zusammenfassenilcs  Referat  mit  Lit.  Zentralbl.  f.  Pathol.,  1904, 
Bd.  15,  p.  917. — Tillmanns.  Ueber  Nervenverletzungen  und  Nervennaht.  Arch.  f. 
klin.  Chir.,  Bd.  27,  1882. — P.  Ziegler.  Untersuchungen  iiber  die  Regeneration  des 
Achsenzylinders  durchtrennter  peripherer  Nerven.     Ebenda,  Bd.  51,  1896,  p.  796. 


VI.     INJURIES   OF   BLOOD   VESSELS 

Subcntaneons  iujuries  of  the  larger  blood  vessels  may  be  associated 
with  contused  and  lacerated  wounds.  Naturally  normal  vessels  are  more 
resistant  to  trauma  than  are  diseased  vessels,  the  walls  of  which  have 
been  weakened  by  arteriosclerosis  or  thinned  by  suppuration  or  by 
pressure  exerted  by  tumors. 

Injuries  of  the  vessels  may  be  associated  with  fractures  and  dislo- 
cations, or  inflicted  when  attempts  are  made  to  reduce  old  dislocations. 
They  may  also  be  caused  by  different  forms  of  trauma. 

The  immediate  and  remote  results  of  an  injury  to  a  vessel  depend 
not  only  upon  the  character  of  the  trauma,  but  also  upon  the  resistance 
of  the  different  tunics  of  the  vessel  involved.  The  intima  is  most  sus- 
ceptible to  trauma.  A  relatively  insignificant  laceration  or  contusion 
such  as  is  produced  by  a  ligature  may  cause  a  destruction  of  the  endo- 
thelium, a  superficial  or  deep  tear  of  the  intima.  A  small  thrombus 
composed  of  blood  platelets  then  forms  at  the  point  of  injury,  the  in- 
tima later  proliferating  to  fill  in  the  defect. 

If  the  media  of  an  artery  is  injured  the  resulting  scar  maj^  gradually 
give  way  under  the  blood-pressure,  a  true  traumatic  aneurysm  then 
developing.  Either  a  mural  or  an  obturating  thrombus  may  form  after 
severe  contusions  or  lacerations  of  arteries  and  veins  in  which  the  in- 
tima is  separated  for  some  distance  and  rolls  in.  The  angiotribe  crushes 
the  intima  and  media  of  vessels,  without  injuring  to  any  extent  the 
adventitia.  The  angiotribe  is  not  employed  very  extensively  at  the  pres 
ent  time,  as  the  thrombus  which  forms  after  its  use  cannot  be  relied 
upon  to  check  haemorrhage.  The  thrombus  is  often  displaced  when  the 
blood  pressure  rises  as  the  patient  is  recovering  from  antesthesia,  and 
ligation  is  therefore  preferred  to  angiotripsy. 

Injuries  of  all  the  coats  of  a  vessel  may  be  followed  by  complete^ 
division  of  the  vessel,  or  a  wound  not  involving  the  complete  circum- 
ference of  the  wall.     The  latter,  accompanied  by  the  extravasation  of 


550  THE   MECHANICAL    INJURIES 

considerable  blood,  may  be  closed  first  by  a  thrombus;  later  by  scar  tis- 
sue, providing  a  pulsating  ha^matoma  or  false  aneurysm  does  not  de- 
velop. Crushed  and  lacerated  vessels  are  often  closed  by  curling  up 
of  the  intima,  so  that  there  is  no  palpable  or  visible  extravasation  of 
blood. 

(a)  SUBCUTANEOUS    INJURIES   OF    VESSELS 

Subcutaneous  injuries  of  the  larger  vessels  occur  most  frequently  in 
the  extremities.  The  injuries  are  produced  by  fractured  or  dislocated 
bones  or  by  some  external  violence.  A  vessel  may  be  ruptured  during 
attempts  at  reduction  of  an  old  dislocation.  The  character  and  extent 
of  the  injury  vary  a  great  deal  in  different  cases.  Abdominal  injuries 
produced  by  blunt  force  (a  blow  or  kick,  being  run  over  by  a  wagon) 
may  be  accompanied  by  rupture  of  mesenteric  vessels,  the  latter  being 
forced  against  the  vertebree.  Fractures  of  the  skull  may  be  complicated 
by  haemorrhage  from  the  middle  meningeal  artery,  which  proves  fatal 
unless  controlled.  It  is  of  medico-legal  interest  to  know  that  the  intima 
of  the  common  carotid  artery  may  be  injured  when  a  person  is  hanged 
or  strangled  by  a  rope. 

Symptoms. — Symptoms  develop  in  these  subcutaneous  injuries  only 
when  some  important  vessel  bleeds  or  is  closed  by  a  thrombus.  Small 
defects  in  the  intima  heal  without  giving  rise  to  symptoms,  or  are  recog- 
nized only  when  an  aneurysm  forms;  for  example,  an  aneurysm  of  the 
abdominal  aorta  following  a  subcutaneous  injury  of  the  abdomen.  If 
a  large  amount  of  blood  is  poured  out  into  the  tissues  surrounding  a 
large  artery  shortly  after  a  subcutaneous  injury  or  fracture,  the  possi- 
bility of  a  tear  or  rupture  of  a  large  vessel  must  be  considered.  If 
a  rough  systolic  murmur  can  be  heard  over  the  seat  of  injury,  a  diag- 
nosis of  some  arterial  lesion  can  usually  be  made  with  certainty.  This 
systolic  bruit,  which  is  called  von  Wahl's  sign,  occurs  after  laceration 
of  the  intima  in  subcutaneous  injuries,  and  is  also  associated  with  punc- 
tured and  gunshot  wounds  of  arteries.  It  is  not  present  after  injuries 
of  small  vessels  (Rotter),  and  may  be  wanting  after  injuries  of  larger 
ones.  The  sign  may  be  caused  by  a  widening  of  the  lumen  when  the 
wound  gapes,  or  by  a  narrowing  of  the  lumen  when  the  intima  is  dis- 
sected up  or  a  mural  thrombus  forms.  A  positive  diagnosis  of  a  com- 
plete rupture  or  closure  by  thrombus  formation  of  the  principal  artery 
can  be  made  if,  after  the  injury,  the  extremity  becomes  cool,  pale,  or 
cyanotic,  and  the  puLse  can  no  longer  be  felt.  Frequently  the  veins 
are  also  closed  by  thrombi  when  the  extremity  has  been  run  over  by 
soTiie  heavy  vehicle  or  by  a  ear. 

Treatment. — An  operation  should  l)e  pci-forme.l  iiimiediately  if  a 
rapidly  enlarging  ha^matoma  forms.     A  hu'iiiorrhage  into  the  abdominal 


MECHANICAL   INJURIES   OF   THE   DIFFERENT   TISSUES  551 

or  cranial  cavities  rapidly  proves  fatal  unless  controlled.  A  haemor- 
rhage into  the  tissues  of  an  extremity  may  cause  gangrene,  as  the  pres- 
sure exerted  by  the  extravasated  blood  prevents  the  establishment  of  a 
collateral  circulation.  If  rupture  of  a  vessel  is  suspected,  an  Esmarch 
constrictor  should  be  applied,  the  haematoma  incised,  the  blood  clots 
removed  with  sterile  gauze,  and  the  injured  point  found.  If  the  artery 
is  essential  to  the  life  of  the  part  or  organ  which  it  supplies,  it  should 
be  closed  by  a  lateral  or  an  end-to-end  suture,  depending  upon  the  char- 
acter of  the  injury.  If  not  essential,  or  the  anastomosis  between  it  and 
other  vessels  is  very  free,  it  should  be  ligated  above  and  below  the  point 
of  injury. 

If  a  diagnosis  of  thrombosis  of  one  of  the  large  vessels  of  an  extrem- 
ity is  made,  the  development  of  a  collateral  circulation  should  be  favored 
by  elevating  the  extremit}^  and  incising  large  ha^matomas. 

(b)  OPEN   INJURIES   OF   LARGER   BLOOD   VESSELS 

Injuries  of  arteries  are  not  infrequently  associated  with  incised,  con- 
tused, punctured,  and  gunshot  wounds;  with  extensive  mutilating  in- 
juries caused  by  explosions,  fragments  of  a  shell,  machines;  with  the 
tearing  away  of  an  entire  extremity,  and  with  complicated  fractures 
and  dislocations.  Veins  are  injured  more  frequently  than  arteries,  for 
they  are  firmly  attached  to  the  fascia  and  are  not  pushed  aside  by  the 
vulnerating  force  as  the  arteries  are.  The  walls  of  veins  are  thinner  and 
less  resistant  to  trauma  than  are  the  walls  of  arteries.  All  sorts  of 
foreign  bodies,  such  as  pieces  of  metal,  glass,  and  wood,  needles,  and 
points  of  knives,  may  lodge  in  or  penetrate  the  walls  of  blood  vessels. 
Blood  vessels  may  also  be  injured  during  operations  by  a  knife,  scissors, 
sharp  hook  or  spoon,  or  by  the  finger  when  a  blunt  dissection  is  made. 
An  erosion  of  a  vessel — which  may  be  caused  by  the  pressure  of  a 
fragment  of  bone,  an  improperly  placed  drainage  tube,  or  a  tracheal 
canula — should  be  classified  with  this  type  of  wounds. 

Injuries  involving  but  a  portion  of  the  vessel  wall  are  differentiated 
from  those  in  which  the  vessel  is  completely  divided. 

Penetrating  wounds  of  vessels,  which  are  not  infrequently  associated 
with  punctured,  gunshot,  and  contused  wounds,  heal  without  giving 
rise  to  symptoms,  unless  an  aneurysm  (aneurysma  traumatieum  verum) 
forms. 

"Wounds  that  penetrate  the  vessel  wall  are  followed  by  hemorrhage, 
if  the  foreign  body  does  not  close  the  opening  in  the  vessel  and  if  the 
wound  canal  in  the  soft  tissues  is  not  closed  b.y  a  clot  or  the  inter- 
position of  muscles  and  fascia.  The  severity  of  the  hemorrhage  depends 
upon  the  size  of  the  wound  and  the  caliber  of  the  vessel.  A  small 
opening  in  a  vein  is  rapidly  closed  by  pressure  exerted  by  extravasated 


552  THE   MECHANICAL   INJURIES 

blood,  and  its  lumen  is  later  occluded  by  a  thrombus.  A  pulsating: 
liai-matoma  (false  aneurysm)  usually  develops  after  a  penetrating  wound 
of  an  artery.  An  arteriovenous  aneurysm  may  develop  if  adjacent 
points  in  the  walls  of  an  artery  and  vein  are  injured  simultaneously. 
Spontaneous  closure  by  thrombus  and  scar  formation  after  wounds  of 
arteries  occurs  only  when  the  wound,  such  as  is  produced  by  a  needle, 
is  narrow. 

The  results  of  the  complete  division  of  an  artery  differ  markedly 
from  those  above  mentioned.  The  artery  gapes,  if  tlie  division  is  clean- 
cut,  and  the  haemorrhage  is  severe,  the  amount  of  blood  which  is  lost 
depending  upon  the  size  of  the  vessel,  unless  its  lumen  is  closed  by  the 
contraction  of  the  surrounding  muscles  or  the  cut  vessel  retracts  from  ' 
the  margins  of  the  wound. 

Venous  and  Arterial  Hsemorrhage. — Venous  hannorrhage  is  distin- 
guished from  arterial  hemorrhage  by  the  color  of  the  blood  and  the 
way  in  which  it  is  discharged. 

In  arterial  haemorrhage  the  blood  appears  as  a  bright  red  stream, 
and  is  discharged  in  jets  which  correspond  to  the  pulse  beat.  Blood 
discharged  from  veins  is  darker  than  that  discharged  from  arteries,  and 
the  blood  either  wells  up  from  the  wound  in  the  vein  or  is  discharged 
in  much  weaker  jets  than  is  arterial  blood.  The  amount  of  blood  lost 
and  the  way  in  which  it  is  discharged  after  injuries  of  veins  depend 
upon  a  number  of  conditions.  If  the  return  flow  is  interfered  with  by 
a  loosely  applied  constrictor  or  a  dependent  position  of  the  limb,  a 
great  amount  of  venous  blood  is  discharged.  Special  conditions  favor- 
ing venous  haemorrhage  are  found  in  the  anatomical  relations  at  the 
base  of  the  neck.  The  veins  in  this  position  are  attached  to  the  resistant 
deep  cervical  fascia,  and  do  not  collapse  when  injured.  Besides,  during 
expiration  the  venous  blood  is  forced  back  into  these  veins,  and  blood 
is  then  discharged  in  jets;  while  during  inspiration  the  blood  is  aspi- 
rated, and  if  there  is  a  wound  in  the  vein  wall,  air  may  be  sucked  into 
the  circulation  (air  embolism).  Aspiration  of  air  into  a  vein  is  indi- 
cated by  a  gurgling  sound.  If  air  reaches  the  heart,  symptoms  of  air 
embolism,  which  is  frequently  fatal,  develop. 

The  characteristic  differences  between  arterial  and  venous  hannor- 
rhage  as  described  above  may  be  wanting  if  the  wound  is  small  or  the 
outflow  is  interfered  with.  Naturally  there  is  nothing  characteristic 
al)out  the  hu'inorrhage  if  an  ni'tery  and  a  vein  are  injured  simultaneously. 

The  results  of  a  division  of  a  vessel  by  blunt  force,  such  as  occurs 
in  contusions  and  lacei*ations,  differ  from  those  following  clean-cut  divi- 
sion. If  vessels  are  divided  in  a  contusion  or  are  lacerated,  the  intima 
and  media  curl  up  and  occlude  the  lumen,  or  at  least  favor  the  devel- 
opment  of   an    obturating   thrombus.      There   riiay   be   no   haemorrhage 


MECHANICAL    INJURIES   OF   THE    DIFFERENT   TISSUES  553 

at'tcr  laceration  of  even  the  veiy  large  vessels,  and  after  severe  in- 
juries death  from  haemorrhage  us  frequently  prevented  ))y  this  curling 
up  of  the  intima  and  media.  When  an  artery  is  put  upon  a  stretch, 
the  intima  ruptures  first,  and  then  the  media  at  a  point  nearer  the 
periphery.  These  two  coats  then  roll  up  and  occlude  the  lumen,  the 
adventitia  being  pulled  out  to  form  a  thin  band  of  tissue,  just  like  a 
heated  glass  canula  is  drawn  out  to  form  a  delicate  capillary  tube.  If 
the  artery  is  twisted  at  the  same  time  that  it  is  torn  the  closure  is  still 
more  firm. 

The  dangers  of  open  injuries  to  vessels  are  partly  due  to  primary 
lui'morrhage,  partly  to  secondary  haemorrhage  and  air  embolism. 

Secondary  Haemorrhage. — Secondary  haemorrhage  occurs  quite  fre- 
quently after  the  primary  haemorrhage  has  subsided  spontaneously.  Sec- 
ondary ha'morrhage  occurs  most  frequently  when  the  knife  or  other 
foreign  body  which  may  have  closed  the  wound  is  withdrawn,  when  the 
thrombus  which  may  have  developed  and  closed  the  wound  after  an  in- 
jury produced  by  blunt  force  is  destroyed  by  suppuration  or  is  dislodged 
by  movements,  or  finally  when  the  arterial  wall  becomes  necrotic  as  the 
result  of  pressure  exerted  by  a  displaced  fragment  of  bone. 

Air  Embolism. — The  entrance  of  air  into  the  injured  internal  jugular 
or  subclavian  vein  during  inspiration  leads  to  the  condition  known  as 
air  embolism.  In  severe  cases  the  patient  dies  inuiiediately  or  after  a 
few  hours;  the  symptoms  being  great  unrest,  a  feeling  of  anxiety, 
marked  dyspnoea,  cyanosis,  weak,  fluttering  pulse,  loss  of  consciousness, 
and  convulsions.  These  symptoms  are  caused  by  interference  with  car- 
diac and  respiratory  functions,  and  by  cerebral  anaemia,  for  the  aspi- 
rated air  reaches  the  right  heart  and  then  passes  into  the  pulmonary 
arteries  interrupting  the  circulation.  As  a  result  of  this  occlusion  of 
the  pulmonary  arteries  the  left  heart  does  not  receive  enough  blood  to 
maintain  the  nutrition  of  the  important  centers  in  the  brain  and  spinal 
cord.  Other  causes  of  death  in  air  embolism,  besides  the  sudden  ana^uia 
of  the  brain  (Panum),  are  paralysis  of  the  heart  caused  by  dilatation 
of  the  right  ventricle  following  the  accumulation  of  air,  and  interference 
with  the  ])ulmonary  circulation   (Senn). 

JMild  cases  of  air  embolism  are  observed  after  operations  more  often 
than  after  injuries.  When  air  embolism  occurs  during  an  operation, 
but  little  air  is,  as  a  rule,  permitted  to  enter  the  vein,  as  the  condition 
is  immediately  recognized  and  the  opening  is  closed  by  pressure.  In 
these  eases  either  no  symptoms  develop  or,  if  they  do,  they  are  mild  and 
transitory.  Notwithstanding  that  the  symptoms  may  be  mild,  an  at- 
tempt should  always  be  made  to  express  the  air,  as  it  is  impossible  to 
estimate  the  amount  which  has  been  aspirated.  The  chest  should  be 
compressed  during  expiration,  and  during  inspiration  digital  pressure 
36 


554  THE  MECHANICAL   INJURIES 

should  be  made  over  tlie  opening  in  the  vein  in  order  to  prevent  the 
aspiration  of  more  air  (Treves).  It  is  well  in  these  cases  either  not  t:) 
wipe  away  the  blood  which  may  have  aecunuilated  over  the  wound  or  to 
flood  the  field  of  operation  wath  salt  solution,  preventing  in  this  way  the 
aspiration  of  air.  When  the  danger  of  air  embolism  has  passed,  the 
vein  should  be  seized  with  an  artery  forceps  without  teeth  and  ligated 
or  sutured.  In  severe  cases  aspiration  of  the  right  ventricle  may  be 
indicated. 

Diagnosis  of  Open  Injuries. — The  diagnosis  of  an  open  injury  of  a 
vessel  is  difficult  only  when  the  most  important  symptom — severe  haem- 
orrhage— is  wanting.  A  non-penetrating  wound  may  escape  notice  wdien 
the  vessel  is  not  freely  exposed  in  the  wound.  It  is  not  unusual  for  the 
primary  haemorrhage  to  cease  rapidly,  and  for  a  ha^matoma  to  fail  to 
develop  when  the  wound  is  made  with  a  delicate  fusiform  instrument 
or  by  a  projectile  of  small  caliber.  This  is  especially  apt  to  happen  if 
the  vessel  is  covered  by  a  thick  resistant  fascia  or  an  aponeurosis  (e.  g., 
the  femoral  artery  in  Hunter's  canal).  In  such  cases  the  position  of 
the  wound  offers  the  only  clew  to  diagnosis,  which  is  often  later  verified 
by  the  development  of  a  bruit  at  the  point  of  injury. 

When  a  large  ha'matoma  develops  after  a  small  wound  of  a  vascu- 
lar region,  it  is  not  always  possible  to  determine  the  nature  of  the 
injury  to  the  vessel.  If  the  pulse  is  wanting  in  the  peripheral  parts,  the 
principal  artery  has  probably  been  completely  divided.  If  the  pulse 
is  present,  but  is  weaker  than  on  the  uninjured  side,  and  a  systolic  bruit 
which  is  transmitted  toward  the  periphery  is  heard,  one  may  conclude 
that  the  artery  has  received  a  lateral  injury.  If  the  bruit  is  transmitted 
both  proximalward  and  distalward,  one  may  conclude  that  a  connnuni- 
cation  has  been  established  between  an  artery  and  a  vein,  following 
simultaneous  injury  of  adjacent  parts  of  the  walls  of  the  vessels 
(arteriovenous  aneurysm). 

Treatment. — The  treatment  consists  of  temporary  and  permanent 
control  of  the  haniiorrhage,  precautions  being  taken  against  loss  of  blood 
and  infection  during  the  ligation  or  suturing  of  the  injured  vessels. 
If  a  diagnosis  of  an  injury  to  an  artery  with  or  without  simultaneous 
injury  of  a  vein  is  made,  the  point  of  injury  should  be  exposed,  even 
if  there  is  no  external  haemorrhage,  the  blood  clots  removed,  and  the 
vessel  ligated  or  sutured.  1'he  treatment  becomes  much  more  difficult 
if  operation  is  delayed  until  an  aneurysm  has  formed.  A  stab  or  gun- 
shot wound  of  a  vessel  may  heal  with  the  development  of  but  a  small 
haematoma. 

After  ligation  or  suture  of  a  large  vessel  an  immobilizing  dressing 
should  be  worn  from  two  to  three  weeks. 

If  tlie  liM'iiiori'hnge  is  severe  the  life  of  the  patient  often  depends 


MECHANICAL   IXJIRIES   OF   THE   DIFFERENT   TISSUES  555 

upon  the  prompt  and  proper  temporary  control  of  the  haemorrhage. 
In  the  extremities  it  can  be  easily  controlled  by  making  pressure  upon 
the  principal  artery  proximal  to  the  point  of  injury,  or  by  constricting 
the  extremity  above  the  wound  by  a  handkerchief,  strap,  piece  of  rope, 
or  suspenders. 

If  the  wound  is  so  situated  that  a  constrictor  cannot  be  applied,  the 
artery  should  be  compressed  proximal  to  the  point  of  injury. 

Venous  haemorrhage  will  be  increased  if  the  veins  are  constricted 
above  the  injury,  but  enough  pressure  is  not  exerted  to  compk'tely  close 
the  artery.  The  femoral  artery  may  be  compressed  against  the  pubic 
bone  with  the  second  and  third  fingers  of  the  left  hand,  reinforced  if 
need  be  by  the  right  thumb.  The  subclavian  artery  in  the  supraclavicu- 
lar fossa  may  be  compressed  against  the  first  rib;  the  connnon  carotid 
artery  against  the  transverse  processes  of  the  cervical  vertebrip.  The 
entire  fist  may  be  used  to  compress  the  abdominal  aorta  against  the 
lumbar  vertebra. 

Hyperextension  may  be  used  instead  of  compression  to  control  haem- 
orrhage from  the  femoral  and  subclavian  arteries.  The  femoral  artery 
may  be  stretched  over  and  closed  by  the  head  of  the  fennir  if  the  thigh 
is  hyperextended ;  the  subclavian  artery  may  be  compressed  between 
the  clavicle  and  first  rib  if  both  elbows  are  bound  behind  the  back,  or  if 
the  arm  on  the  side  in  question  is  drawn  forcibly  backward  and  to  the 
opposite  side. 

Haemorrhage  is  most  dangerous  from  those  arteries  which,  because 
of  anatomical  relations,  are  constricted  or  compressed  with  difficulty. 
In  liannorrhage  from  one  of  these  vessels,  compression  should  be  resorted 
to  innnediately,  the  possibilities  of  infection  being  disregarded — as,  for 
example,  in  haemorrhage  from  the  innominate  artery  or  vein. 

Permanent  control  of  haemorrhage  is  accomplished  by  ligation  or 
suture  of  the  injured  vessel. 

Ligation  of  Blood  Vessels. — The  ligature  may  be  emploj^ed  whenever 
closure  of  the  vessel  in  question  is  not  followed  by  severe  nutritional 
disturbances.  In  ligating  a  vessel  the  injured  point  is  first  exposed 
under  artificial  ischamiia.  If  the  vessel  is  completely  divided,  both  ends 
should  be  seized  witli  artery  forceps,  drawn  somewhat  out  of  the  wound 
and  ligated.  In  a  lateral  injury  the  vessel  should  be  freed  a])ove  and 
below  the  point  of  injury  from  its  sheath,  and  then  with  th(!  aid  of  an 
aneurysm  needle  a  catgut  ligature  should  be  passed  about  the  vessel 
above  and  below  the  wound.  The  segment  of  the  vessel  lying  between 
the  ligatures  should  then  be  resected. 

Suture  of  Blood  Vessels. — An  attempt  should  be  made  to  sntiii-e  the 
vessels  or  vessel,  if  both  the  ai'tery  and  vein  are  injured,  or  if  ligation 
of  the  vessel  is  followed  by  severe  nutritional  disturbances,   such  as 


556  THE   MECHANICAL    INJURIES 

occur  frequently  after  ligation  of  the  common  carotid  artery,  more 
rarely  after  ligation  of  the  femoral  artery.  A  lateral  or  a  circular 
suture  may  be  performed,  depending  upon  the  conditions  found  at  the 
time  of  operation. 

Lateral  suture  was  attempted  before  circular  suture.  The  suture 
was  first  attempted  upon  veins,  after  it  had  been  demonstrated  by 
experimental  work  (Braun)  and  by  clinical  experience  (Schede,  1882) 
that  thrombosis  did  not  occur  if  the  operation  was  performed  asep- 
tically. 

Important  animal  experiments  in  circular  suture  of  vessels  were  per- 
formed by  Gluck  (1882)  and  by  Jassinowsky  (1891).  The  latter  espe- 
cially demonstrated  that  in  spite  of  the  technical  difficulties,  a  cir- 
cular suture  can  be  inserted  without  secondary  ha?morrhage  or  thrombvis 
formation  occurring  and  without  an  aneurysm  developing.  The  first 
circular  suture  of  an  artery  in  man  was  performed  by  Murphy  in  1897, 
the  lumen  of  the  femoral  artery  being  reestablished. 

While  the  suture  is  being  inserted  the  artery  should  be  closed  above 
and  below  the  point  of  injury  by  digital  pressure  or  by  a  delicate  clamp 
(the  blades  of  which  are  covered  with  rubber  tubing,  such  as  a  Crile 
clamp).  The  ordinary  haemostatic  forceps  should  not  be  used,  as  it 
injures  the  endothelium,  causing  thrombus  formation. 

[Carrel's  method  of  suture  is  the  most  successful;  a  very  fine  needle 
and  silk  which  is  vaselined  are  used  in  performing  the  suture.] 

A  lateral  suture  nmy  be  emploj^ed  in  closing  longitudinal  wounds, 
and  transverse  and  oblique  wounds  which  do  not  involve  more  than 
one  half  of  the  circumference  of  tlie  vessel.  In  applying  this  suture  a 
fine  non-cutting  needle  armed  with  the  finest  silk,  which  should  be 
vaselined,  is  carried  through  all  of  the  coats  of  the  vessel,  a  continuous 
suture  being  inserted  (Doerfier).  The  edges  of  the  wound  should  be 
held  firmly  together,  and  the  margin  of  the  endothelium,  in  which  the 
proliferative  changes  first  occur,  should  be  accurately  approximated. 
Some  interrupted  sutures  which  include  only  the  adventitia,  and  the 
connective  tissues  about  the  vessel  should  then  be  inserted  to  protect  the 
line  of  suture.  After  the  operation  is  completed,  the  forceps  should 
be  gradually  removed  so  that  the  stitches  may  gradually  tighten  as  the 
blood  courses  through  the  vessel.  It  is  sometimes  advisable  to  exert 
gentle  pressure  over  the  line  of  suture  for  a  little  while  before  closing 
the  wound. 

The  same  precautions  sliould  be  taken  in  applying  a  circular  suture 
as  described  above.  The  circular  suture  is  employed  to  reunite  the  ends 
of  M  conipletely  divided  jii'torv  or  close  a  large  defect.  It  is  more  dif- 
fif-nlt  to  :i|)])ly  ;i  cifcnbif  tluin  a  lateral  suture.  JMurphy's  method,  in 
which  the  pi-oximal  end  is  invaginated  into  the  distal  by  sutures  passed 


MECHANICAL   INJURIES  OF   THE   DIFFERENT  TISSUES  557 

Ihrouuli  all  the  coats  of  the  vessels,  presents  inaiiy  teelinieal  (liflienlties. 
[Carrel's  method  is  best  suited  for  circular  suture.] 

Mechanical  Methods  for  Repairing  Vessels. — Of  the  diiferent  me- 
chanical methods  that  introduced  by  Payr  is  the  most  successful.  The 
magnesium  tube  used  by  him  in  making  an  anastomosis  is  very  thin, 
UK^asures  from  0.3-1  cm.  in  length,  and  presents  two  grooves  upon  its 
outer  surface.  The  tubes,  of  course,  come  in  different  sizes,  which  cor- 
respond to  those  of  the  arteries  for  which  they  are  employed.  In  mak- 
ing an  anastomosis,  the  proximal  end  of  the  artery  or  vein  is  drawn 
through  the  tube  and  is  then  everted  by  sutures  or  forceps  so  that  the 
endothelium  faces  outward.  The  everted  end  is  then  tied  with  a  fine 
silk  ligature  in  the  second  groove.  The  tube  covered  by  the  proximal 
end  is  then  slipped  into  the  distal  end,  which  is  then  tied  over  the  tube. 
Endothelium  is  then  applied  to  endothelium,  and  there  is  no  foreign 
body  in  the  blood  stream.  Union  occurs  within  ten  days,  and  then  the 
magnesium  tube  is  gradually  absorbed.  A  distance  of  5  cm.  may  be 
overcome  by  placing  the  extremity  in  the  proper  position,  rendering 
suture  without  tension  possible. 

Naturally  lateral  and  circular  suture  can  only  be  performed  on  the 
larger  vessels.  Smaller  vessels,  about  3  mm.  in  diameter,  are  sutured 
with  difficulty,  and  besides  thrombosis  is  apt  to  occur. 

Bepair  of  Wounds  in  Vessels. — Agglutination  of  the  margins  of  the 
wound,  assisted  by  the  formation  of  a  thrombus  composed  of  blood  plate- 
lets and  of  a  layer  of  fibrin,  is  the  first  step  in  the  repair  of  arteries 
and  veins  after  ligation  or  suture.  Evidences  of  endothelial  prolifera- 
tion may  be  found  a  few  hours  after  ligation  or  suture.  The  rapidly 
growing  endothelial  cells  repair  the  defect  upon  the  inner  surface  of 
the  vessel,  grow  in  between  the  edges  of  the  wound,  and  cover  the  sutures 
which  have  been  inserted.  The  fibrous  elements  of  the  media  and  ad- 
ventitia  soon  proliferate  and  aid  in  repair.  But  few  elastic  fibers  are 
found  in  the  adventitia  and  media.  They  are,  however,  relatively  nu- 
merous in  the  intinia  (Jacobsthal).  The  same  changes  are  observed  in 
the  spontaneous  healing  of  small  wounds  of  vessels,  provided  the  ha?mor- 
rhage  is  controlled  by  the  resistance  offered  by  the  soft  tissues.  The 
clot  which  then  closes  the  wound  in  the  vessel  wall  is  organized  to  form 
a  scar. 

VII.     INJURIES  OF   LYMPHATIC   VESSELS 

Injuries  of  lymphatic  vessels  are  of  less  importance  surgically  than 
are  injuries  of  blood  vessels. 

Injury  of  the  thoracic  duct  or  of  one  of  its  largest  branches  is  the 
most  important  of  the  injuries  affecting  lymphatics.  The  thoracic  duct 
may  be  injured  at  its  point  of  junction  with  the  left  subclavian  vein 


558  THE  MECHANICAL  INJURIES 

during  the  removal  of  deeply  situated  and  adherent  tuberculous  lymph 
nodes.  It  may  also  be  divided  in  stab  or  gunshot  wounds  of  the  supra- 
clavicular fossa.  The  loss  of  chyle  following  its  division  may  cause 
severe  nutritional  disturbance.  Usually,  however,  the  discharge  of  chyle 
gradually  ceases  as  healing  progresses.  If  the  divided  duct  is  seen  in 
the  wound,  the  thoracic  end  should  be  grasped  by  artery  forceps  and 
ligated.  If  the  divided  duct  cannot  be  found,  the  external  discharge 
of  chyle  can  easily  be  prevented  by  packing  the  wound  with  gauze.  In 
the  majority  of  cases  division  of  the  duct  is  not  followed  by  bad  results, 
as  a  rich  collateral  circulation  is  soon  established  or  the  duct  empties 
into  the  vein  by  a  number  of  branches  (Wendel). 

Injuries  of  the  thoracic  portion  of  the  duct  may  be  associated  with 
contusions  of  the  chest  and  fractures  of  the  thoracic  vertebrae  If  death 
is  not  caused  by  the  injury  to  the  chest  or  vertebra-,  chyle  is  then  poured 
out  into  both  pleural  cavities.  Chylothorax  may  also  be  caused  by  the 
pressure  exerted  by  tuberculous  or  carcinomatous  lymph  nodes  upon 
the  duct. 

A  chylous  ascites  may  be  caused  in  the  same  ways  as  mentioned 
above. 

Exploratory  puncture  reveals  a  milky  fluid  which  contains  fat,  albu- 
min, and  usually  sugar,  if  there  is  a  chylothorax  or  a  chylous  ascites. 

Recovery  may  take  place  spontaneously  after  traumatic  rupture  of 
the  duct,  as  the  opening  in  it  may  be  closed  by  the  pressure  of  tlie 
extravasated  fluid.  If  in  chylothorax  the  respirations  become  embar- 
rassed, the  fluid  should  be  aspirated.  Only  enough  should  be  removed 
to  relieve  the  respirations,  as  more  fluid  is  poured  out  after  aspiration. 

Lymphatic  vessels  of  ditt'erent  sizes  are  injured  in  all  wounds  and 
in  all  subcutaneous  injuries.  Large  amounts  of  lymph,  however,  rarely 
accuuuilate,  as  the  collateral  ]ymi)hatic  circulation  is  very  free,  and  th(> 
lymph  passes  into  other  vessels.  In  many  subcutaneous  injuries  lymph 
is  extravasated  and  assists  in  the  formation  of  the  swelling.  In  subcu- 
taneous separation  of  the  skin  (decoUement)  lymph  mingles  with  the 
blood,  giving  rise  to  a  characteristic  clinical  picture. 

Dilated  lymphatic  vessels  in  the  skin  may  rupture  spontaneously  or 
burst  as  the  result  of  a  blow  or  pressure.  A  permanent  lymph  flstula 
may  then  form. 

LrrERATUiiE. — Apollonio.  Mikroskopisclio  Unlersuchungen  iiber  dio  Organisation 
lies  Unterbindungsthroinhiis  in  den  Artcrien.  Px'itr.  z.  ])a(h()l.  Anat.,  Bd.  '.i,  ISSS. — 
liaumgarten.  Uolx-r  die  Hcliicksale  des  Blutes  in  d()j)j)elt,  unterhundenen  Gefiisstreeken. 
Wien.  med.  Wochenschr.,  1902,  No.  45; — Ueber  die  sog.  Organisation  des  Throm- 
bus. Centralbl.  f.  die  med.  Wissensch.,  1876,  p.  593. — v.  Brumi.  Beitrag  zur 
traumatischen  Gangran  durch  Ruptur  der  inneren  Arterienhiiute.  Beitr.  z.  klin.  Chir., 
Bd.  41,  1903. — Delbct.  Maladies  chirurg.  des  Arteres,  Dentu  et  Delbet.  Trait6  de 
chir,,  Paris,   1897,  p.   141,   Part  IV. — Ddrfler.     Ueber  Arteriennaht.     Beitr.  z.   klin. 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  559 

Chir.,  Bd.  25,  1899,  p.  781. — Fischer.  Ueber  die  Gefahren  des  Lufteintrittes  in  die 
Venen  wiihrend  einer  Operation,  v.  Volkmanns  Samnil.  klin.  Vortriige,  1877,  No.  113. — 
Hare.  The  Entrance  of  Air  into  the  Veins.  Americ.  Journal  of  the  Med.  Sciences,  1902, 
November. — Heller.  Ueber  traumatische  Pfortaderthronibose.  Verhandl.  d.  pith. 
Gesellsch.,  Zentralbl.  f.  allgem.  Pathol.,  Bd.  15,  Erganzungsheft,  p.  182,  1904. — Hupjtier. 
ITeber  Gefassnaht,  Gefiisstransplantationen  und  Replantation  von  araputierten  Ex- 
tremitaten.  Arbeiten  aus  v.  Bergmanns  Klinik,  17,  1904,  mit  Lit.  und  Arch.  f.  klin. 
Chir.,  Bd.  70,  1903,  p.  417. — Jacobsthal.  Zur  Histologie  der  Arteriennaht.  Beitr.  z. 
klin.  Chir.,  Bd.  27,  1900,  p.  199. — Jordan,  Luftasjjiration  in  die  Venen  des  Halses. 
Handb.  d.  prakt.  Chir.,  2.  Aufl.,  Bd.  2,  p.  43. — Korte.  Ueber  Gefassverletzungen  bei 
Verrenkungen  des  Oberarmes.  Arch.  f.  klin.  Chir.,  Bd.  27,  1882,  p.  631. — Kiimmell. 
Chylothorax.  Mit  Lit.  im  Handb.  d.  prakt.  Chir.,  2  Aufl.,  Bd.  2,  p.  497. — Linser. 
Ueber  Zirkulationsstorungen  im  Gehirn  nach  Unterbinr'ung  der  Vena  jugul.  int.  Beitr. 
z.  klin.  Chir.,  Bd.  28,  1900,  p.  642. — Marchuml.  Der  Process  der  Wundheilung.  Deutsche 
Chir.,  1901,  Wunden  der  Gefasse,  p.  330. — Payr.  Beitrage  zur  Technik  der  Blutgefass- 
und  Nervennaht.  Chir.  Kongr.-Verhandl.,  1900,  II,  ji.  593  and  Arch.  f.  klin.  Chir., 
Bd.  62,  p.  67; — ^Weitere  Mitteilungen  iiber  Verwendung  des  Magnesium  bei  der 
Naht  der  Blutgefasse.  Ibid.,  Bd.  64,  1901; — Zur  Frage  der  zirkularen  Vereini- 
gung  von  Blutgefjissen  mit  resorbierbaren  Prothesen.  Ibid.,  Bd.  72,  1903.  —  E. 
Pick.  Ueber  die  Rolle  der  Endothelien  bei  der  Endarteritis  post  ligaturam.  Zeit- 
schr.  f.  Heilkunde,  Bd.  6,  1885,  p.  457. — Raab.  Ueber  die  Entwicklung  der  Narbe 
im  Blutgefiiss  nach  der  Unterbindung.  Arch.  f.  klin.  Chir.,  Bd.  23,  1879,  p.  156; 
■ — Neue  Beitrage  zur  Kenntnis  der  anatomischen  Vorgiinge  nach  Unterbindung  der 
Blutgefasse  beim  Menschen.  Virchows  Arch.,  Bd.  75,  1879,  p.  451. — Rotter.  Ueber 
Stichverletzungen  der  Schliisselbeingefasse.  v.  Volkmanns  Samml.  klin.  Vortr.,  1893, 
N.  F.,  No.  72.— Schmitz.  Die  Arteriennaht.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  66,  1903. 
— Schopf.  Verletzungen  des  Halsteiles  des  Ductus  thoracicus.  Wien.  klin.  Wochen- 
schrift,  1901,  No.  48. — Senn.  An  Experiment  and  Clinical  Study  of  Air-Embolism. 
Centralbl.  f.  Chir.,  1886,  No.  23. — Thole.  Querdurchtrennung  des  Duct,  thoracicus 
am  Halse.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  58,  1900,  p.  95. — v.  Wahl.  Die  Diagnose 
der  Arterien verletzungen.  v.  Volkmanns  Samml.  klin.  Vortr.,  1885,  No.  258. — -Weudcl. 
I^eber  die  Verletzung  des  Ductus  thoracicus  am  Halse  und  ihre  Heilungsmoglichkeit. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  48,  1898,  p.  437. 


VIII.     INJURIES  OF  JOINTS 

(a)  SUBCUTANEOUS    INJURIES 

Subcutaneous  injuries  of  joints  may  be  divided  into  contusions, 
sprains,  and  dislocations. 

A  contusion  may  be  caiised  by  direct  or  indirect  violence.  In  the 
former  the  force  is  applied  over  the  joint,  while  in  the  latter  it  is  trans- 
mitted from  some  distant  point,  the  articular  surfaces  being  driven 
together.  For  example,  the  knee  or  hip  joints  may  be  contused  by  a  fall 
upon  the  feet,  the  elbow  joint  by  a  fall  upon  the  hand. 

In  contusions  caused  by  direct  force  the  soft  tissues  surrou7iding  the 
joint  are  injured  as  well  as  the  synovial  membrane.  In  contusions  caused 
by  indirect  force,  fragments  of  bone  may  be  separated,  the  articular 
surfaces  fissured,  the  spongy  ends  of  the  bones  crushed,  and  the  articular 


560  THE   MECHANICAL   INJURIES 

cartilage  separated  from  the  subjacent  bone   by  an   accumnlation  of 
blood. 

Hsemarthrosis. — The  most  prominent  symptom  of  a  contusion  of  a 
joint  is  an  extravasation  of  blood  into  the  joint  cavity  (haemarthrosis). 
The  contour  of  the  joint  is  changed,  as  its  normal  lines  are  obliterated 
by  the  distention  of  the  capsule.  The  ha?marthrosis  develops  rapidly 
after  the  injury,  and  reaches  its  maximum  development  on  the  following 
day.  Movements  of  the  joint  involved  are  painful  and  its  function  is 
interfered  with. 

The  prognosis  of  a  contusion  uncomplicated  by  a  fracture  and  asso- 
ciated with  but  a  small  extravasation  of  blood  is  good.  Recovery  with 
good  function  usually  occurs  within  a  short  while. 

Functional  disturbance  may  develop  if  the  blood  is  incompletely  or 
slowly  absorbed.  The  absorbing  poAver  of  synovial  membrane  is  not 
great,  for  the  lymphatic  plexuses  are  not  in  direct  communication  with 
the  joint  cavity,  differing  in  this  way  from  the  lymphatic  plexuses  of 
serous  cavities.  Large  exudates  are  not  removed  unless  absorption  is 
favored  by  compression,  massage,  and  gentle  active  and  passive  move- 
ments, or  unless  the  capsule  is  torn  opening  in  this  way  lymphatics  of 
the  surrounding  tissues.  Coagulated  blood  causes  the  greatest  disturb- 
ance. 

Riedel  has  shown  by  experimental  work  on  animals  that  one  third 
of  the  blood  poured  out  into  a  joint  becomes  coagulated.  The  changes 
which  blood  undergoes  in  a  human  joint  vary.  Sometimes  coagulation 
occurs  early,  while  in  other  cases  the  blood  remains  fluid  for  a  number 
of  weeks.  In  those  cases  in  which  the  blood  remains  fluid  for  a  long 
time  there  is  always  considerable  fat  in  the  joint  cavity  which  is  appar- 
ently derived  from  contused  bone  marrow.  Fat  probably  prevents  or 
delays  the  coagiilation  of  blood. 

Regressive  changes  occur  much  more  slowly  in  clotted  than  in  fluid 
blood,  and  clotted  blood  is  absorbed  much  less  rapidly.  The  irritation 
of  the  synovial  membrane  induced  by  the  blood  may  be  followed  by  a 
serous  exudate,  giving  rise  to  the  clinical  picture  of  a  chronic  or  recur- 
ring hydrops.  Long-continued  immobilization  of  such  a  joint  may  be 
f()ll()\v(!d  by  organization  of  the  fi])i'inous  masses  lying  between  the 
articuhir  surfaces,  causing  fibrous  anchylosis.  A  large  chronic  exudate 
may  so  distend  and  weaken  the  capsule  that  the  joint  becomes  flail. 
Other  complications  of  a  contusion  are  subcutaneous  suppuration  and 
tuberculosis  of  the  injured  joint.  They  may  develop  as  liivmatogenous 
infections  or  after  the  rnjitnre  l)y  the  force  causing  the  contusion 
of  the  capsule  of  some  latent  focus.  Infections  of  the  luematoma 
and  joint  may  develop  from  small  wounds  in  the  skin  and  from 
excoriations. 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  561 

Diagnosis. — The  diagnosis  of  a  simple  contusion  of  a  joint,  nncom- 
plieated  by  a  fracture,  is  based  upon  the  character  of  the  injury  and 
the  findings  elicited  by  an  examination.  Distention  of  the  capsule,  fluc- 
tuation, the  so-called  "  snowball  "  crepitation,  which  can  be  elicited  by 
pressure  at  certain  points  and  is  caused  by  displacement  of  blood  clots, 
and  the  signs  of  a  contusion  of  the  soft  tissues  are  indicative  of  a  haemar- 
throsis.  Severe  pain  elicited  by  pressure  made  at  definite  points  and 
abnormal  lateral  mobility  indicate  the  laceration  of  ligaments.  Frac- 
tures involving  most  of  the  joints  are  very  typical.  Fissures  and  frac- 
tures of  the  epiphysis  without  displacement  cannot  be  recognized  unless 
a  Koentgen-ray  examination  is  made. 

Treatment. — The  first  indication  in  the  treatment  of  a  contusion  of  a 
joint  is  to  put  the  part  at  rest.  If  one  of  the  joints  of  the  lower  ex- 
tremity is  involved  the  patient  should  remain  in  bed.  If  a  bandage 
which  exercises  mild  compression  is  applied  immediately,  and  the  joint 
is  then  immobilized  upon  a  papier-mache  or  a  molded  plaster-of-Paris 
splint,  the  pain  is  relieved  more  rapidly  and  less  blood  is  poured  out 
into  the  joint  than  when  an  icebag  is  applied  and  massage  is  employed 
to  hasten  absorption.  The  immobilizing  dressing  should  not  be  em- 
ployed longer  than  one  week,  provided  there  is  no  fracture.  At  the  end 
of  a  week  massage,  active  and  passive  motion,  and  baths  should  be  be- 
gun in  order  to  prevent  stiffness  of  the  joint.  No  weight,  however, 
should  be  borne  upon  the  joint  at  this  time.  If  the  blood  is  absorbed 
slowly  and  the  exudate  is  large,  it  may  be  necessary  and  advantageous 
to  aspirate  the  joint.  After  aspiration  a  dressing  which  exercises  mild 
compression  should  be  applied  over  the  joint.  Such  a  dressing  should 
be  worn  for  some  weeks. 

Sprains. — An  injury  in  which  there  is  a  sudden  momentary  displace- 
ment of  bones  entering  into  a  joint,  the  parts  returning  immediately 
to  their  normal  relations,  is  classified  as  a  sprain. 

A  sprain  may  be  caused  by  movements  carried  beyond  the  normal 
range  of  motion  peculiar  to  the  joint  (for  example,  a  spi'ain  caused 
by  hyperflexion  or  hyperextension  of  a  hinge  joint),  or  by  some  move- 
ment which  normally  does  not  occur  in  the  joint  involved  (for  example, 
a  sprain  of  a  hinge-joint  caused  by  forceful  attempts  at  rotation).  The 
cause  of  sprains  of  the  various  joints  dift'ers.  The  most  frequent  and 
best-known  examples  are  sprains  of  the  ankle  caused  by  a  misstep,  and 
sprains  of  the  wrist  caused  by  falling  upon  the  flexed  or  extended  hand. 
Next  in  order  of  frequency  are  sprains  of  the  knee  caused  by  abduction 
or  rotation  of  the  leg.  Joints  with  a  very  free  range  of  motion,  such 
as  the  shoulder  and  hip,  are  more  frequently  dislocated  than  sprained. 

PatJiology  of  a  Spniin. — The  capsule  and  ligaments  are  nearly  always 
lacerated  at  the  points  where  they  have  been  exposed  to  the  greatest 


562  THE   MECHANICAL   INJURIES 

tension  during  the  exaggerated  or  abnormal  movements.  The  tear  may- 
involve  one  or  all  of  the  layers  of  the  capsule  and  may  vary  greatly 
in  extent.  Strong  accessory  bands  in  a  capsular  ligament  are  often  very 
resistant  and  frequently  are  not  torn,  a  piece  of  bone  to  which  they  are 
attached  being  torn  away  (as  in  Colles'  and  Pott's  fractures).  Bony 
prominences,  such  as  the  coracoid  process,  tendons  and  muscles,  inti- 
mately related  to  the  joint  and  inhibiting  the  movements  of  the  same, 
may  be  torn  olf  and  partially  or  completely  ruptured.  Intra-articular 
fibrocartilages  may  be  displaced  and  parts  of  the  capsule  or  tendons  acd 
muscle  may  become  caught  between  the  articular  surfaces. 

Symptoms. — The  first  symptom  of  a  sprain  is  severe  pain.  The  pain 
soon  subsides  if  only  the  capsular  ligament  is  lacerated.  If  the  liga- 
ments are  badly  torn  or  if  there  is  also  a  fracture,  the  pain  persists 
until  the  part  is  immobilized.  Within  a  few  hours  the  joint  becomes 
swollen,  as  blood  is  extravasated  into  the  joint  cavity  and  periarticu- 
lar tissues.  Ecchymoses  develop  in  the  skin  surrounding  the  joint, 
especially  at  the  points  where  the  ligaments  have  been  lacerated  or 
a  fragment  of  bone  separated.  Movements  are  avoided  and  no  at- 
tempt is  made  to  bear  weight  upon  the  joint,  as  the  pain  is  increased 
thereby. 

Clinical  Course  and  Prognosis. — The  clinical  course  and  prognosis 
of  a  sprain  are  much  the  same  as  those  of  a  contusion.  Simple  sprains 
without  extensive  laceration  of  the  ligaments  or  injuries  of  bones  go 
on  to  complete  recovery  in  a  short  time.  If,  on  the  other  hand,  the 
articular  cartilages  are  displaced  or  a  piece  of  the  capsule  becomes 
incarcerated,  the  pain  persists  for  a  long  while.  A  fracture,  if  not  rec- 
ognized or  if  neglected,  may  heal  in  malposition,  causing  marked  func- 
tional disturbance.  Too  early  use  of  an  extremity  after  the  laceration 
of  important  ligaments  may  cause  abnormal  mobility  (lateral  mobility 
of  the  knee  joint),  and  faulty  positions  (genu  valgum,  pes  valgus). 
Sprains  readily  recur,  as  the  ligaments  which  may  not  have  completely 
healed  become  weak  and  relaxed  when  used  early. 

Diagnosis. — The  diagnosis  of  a  sprain  is  not  always  easily  made. 
The  character  of  the  injury,  and  the  development  of  a  painful  swelling 
of  the  joint  which  interferes  with  every  motion  make  the  diagnosis  of 
a  sprain  probable.  The  laceration  of  a  ligament,  if  there  is  no  fracture, 
is  recognized  by  tender  points  corresponding  to  the  position  of  the  tear. 
In  sprains  of  the  ankle  joint  these  tender  points  are  found  over  the 
deltoid  ligament ;  in  sprains  of  the  knee  joint  about  the  joint  line.  Even 
if  but  a  small  hannatoma  has  developed,  these  points  will  be  more  re- 
sistant than  corresponding  points  upon  the  uninjured  side. 

The  deformities  associated  with  fractures  involving  joints  (Pott's 
and  Colles'  fractures,  fracture  of  the  ])atella)  .-u'e  usually  characteristic 


MECHANICAL   INJURIES   OF  THE   DIFFERENT  TISSUES  563 

and  typical.  These  fractures  should  not  be  mistaken  for  sprains.  Quite 
frequently,  however,  but  a  small  frayiiicnt  of  bone  is  lu'okcn  off  and  the 
typical  deformity  is  concealed  by  a  htematoma.  In  doubtful  cases  a 
positive  diagnosis  can  be  made  by  a  Roentgen-ray  examination.  Roent- 
gen-ray examinations  have  shown  that  snuill  fragments  of  bone  are  more 
frequently  torn  off'  in  sprains,  and  that  tissures  are  more  common  than 
clinical  findings  would  seem  to  indicate.  The  presence  or  absence  of 
injuries  to  muscles  and  tendons  should  be  determined  by  palpation  and 
a  test  of  function. 

Treatnuiit. — The  treatment  should  be  the  same  as  already  described 
in  discussing  contusions  of  joints.  Only  when  the  exudate  is  small, 
when  the  interference  with  function  is  not  marked,  and  there  is  no 
laceration  of  the  ligaments  should  massage  be  begun  innnediately.  In 
all  other  cases  an  innnobilizing  dressing  should  be  enq)loyed  for  at 
least  one  week.  If  the  ligaments  are  extensively  lacerated,  or  if  there 
is  a  fracture,  an  immobilizing  dressing  should  be  worn  for  a  number  of 
weeks.  It  should  be  so  applied,  however,  that  it  can  be  easily  removed, 
so  that  massage  may  be  employed  and  gentle  active  and  passive  motion 
begun  when  indicated. 

Persistent,  marked  functional  disturbances,  which  may  be  caused  by 
incarceration  of  a  part  of  the  capsule,  or  extensive  laceration  of  the 
ligaments  or  displacement  of  the  semilunar  cartilages,  may  demand 
operative  interference.  An  incarcerated  portion  of  the  capsule  should 
be  removed,  a  lacerated  ligament  sutured,  a  displaced  semilunar  carti- 
lage sutured  in  place  or  removed. 

The  tissues  along  the  lines  of  attachment  of  the  capsular  and  intra- 
capsular ligaments  may  be  crushed  or  lacerated  in  both  severe  and 
insignificant  contusions  and  sprains.  Such  injuries  are  especially  apt 
to  occur  at  the  points  of  attachment  of  the  crucial  ligaments  of  the 
knee  joint.  Small  fragments  of  cartilage  may  be  torn  off  when  con- 
siderable tension  is  exerted  upon  the  ligaments.  The  separation  of  small 
pieces  of  cartilage,  together  with  small  fragments  of  bone,  occurs  most 
frequently  in  the  knee  and  elbow  joints. 

Floating  Cartilages. — These  fragments,  which  may  become  quite 
large,  measuring  several  centimeters  in  diameter,  may  be  partially  or 
completely  separated  from  the  articular  cartilages.  They  form  one  class 
of  the  so-called  joint  bodies  or  "  joi)it  mice.''''  Apparently  the  separa- 
tion from  the  articular  cartilage  takes  place  slowly,  and  is  due  to  the 
granulation  tissue  which  develops  after  a  piece  of  cartilage  has  been 
partially  detached  by  some  trauma,  or  has  become  necrotic  as  the  result 
of  an  injury  (Konig).  A  history  of  a  previous  injury  to  the  joint  can 
usually  be  elicited  in  these  cases  of  floating  cartilage.  Then  after  a 
period  varying  in  length  from  days  to  years  the  characteristic  symptoms 


564  THE   MECHANICAL   INJURIES 

of  a  tioatinjf  cartilage — locking  of  IIk  joint  (uul  suhsequent  sijnovilis 
— develop.  The  time  intei'vcning  between  the  injury  and  the  develop- 
ment of  the  symptoms  of  a  floating'  cartilage  depends  npon  the  length 
of  time  required  for  the  separation  of  the  partially  detached  or  necrotic 
piece  of  cartilage.  The  symptoms  caused  by  traumatic  floating  car- 
tilages do  not  differ  from  those  caused  by  pathological  floating  carti- 
lages {vide  Arthritis  Deformans).  The  symptoms  associated  with  the 
former  recur  more  frequently.  Incarceration  of  a  floating  cartilage 
between  the  articular  surfaces  of  a  joint  produces  severe  pain  and  in- 
hibits motion.  The  pain  persists  and  the  joint  remains  locked  until  the 
cartilage  escapes  from  between  the  articular  surfaces  spontaneously,  or 
as  the  result  of  appropriate  manipulations  which  the  individual  soon 
learns  to  make  after  the  joint  has  been  locked  a  few  times.  A  serous 
synovitis  develops  after  the  joint  has  been  unlocked.  If  the  joint  be- 
comes locked  repeatedly  the  serous  synovitis  becomes  chronic  and  the 
capsule  becomes  thickened. 

Some  traumatic  floating  cartilages  are  absorbed,  while  others  remain 
and  are  altered,  as  has  been  determined  by  animal  experiments  and  his- 
tological examinations  (Hildebrand,  Barth,  A.  Schmitt,  Schmieden,  and 
others).  A  floating  cartilage  may  become  infiltrated  and  digested  by 
the  granulation  tissue  which  develops  from  the  synovial  membrane  or 
articular  cartilage.  Frequently,  according  to  Barth,  the  absorption  is  not 
complete,  the  rough  surfaces  of  the  cartilage  being  merely  smoothed  ot¥. 
The  floating  cartilage  may  then  remain  attached  to  the  synovial  mem- 
brane, later  being  surrounded  by  osteoid  and  cartilaginous  tissue.  If 
the  pedicle  attaching  it  to  the  synovial  membrane  is  ruptured  by  some 
slight  trauma  the  body  becomes  free  again.  Separated  fragments  of 
cartilage  w^hich  do  not  become  attached  to  the  synovial  membrane  may 
also  be  retained.  Both  regressive  and  progressive  changes  may  occur  in 
these  fragments  (Schmieden).  A  joint  body  may  become  calcified  after 
persisting  for  some  time. 

The  shape  of  a  floating  cartilage  may  be  changed.  x\  joint  body 
which  has  but  recently  become  detached  may  be  recog-nized  by  the 
smooth  layers  of  the  articular  cartilage  and  the  irregular  processes  of 
spongy  l){)ne  which  lie  beneath  the  latter.  Later  the  joint  body  becomes 
completely  covered  by  nodular  elevations  of  cartilage,  and  the  trau- 
matic can  no  longer  be  differentiated  from  the  pathological  variety. 
Remnants  of  articular  cartilage,  which  may  be  recognized  with  dif- 
ficulty in  old  calcified  preparations,  may  indicate  the  origin  of  these 
floating  cartilages.  Even  if  articular  cartilage  is  found,  it  cannot  be 
said  that  the  joint  body  is  of  traumatic  origin,  for,  according  to  Konig, 
pieces  of  articular  cartilage  become  separated  spontaneously  in  osteo- 
chondritis dissecans. 


MECHANICAL   INJURIES  OF   THE   DIFFERENT  TISSUES  565 

Dislocations. — A  dislocation  is  a  permanent,  abnormal,  total,  or  par- 
tial displacement  from  each  other  of  the  articular  portions  of  the  bones 
entering-  into  the  formation  of  a  joint  (Stimson).  A  partial  or  incom- 
plete dislocation  is  also  called  a  sublnxation. 

Dislocations  are  classified  as  traumatic,  congenital,  and  pathological. 

Traumatic  dislocations  may  be  caused  by  direct  or  indirect  violence, 
the  bones  entering  into  the  joint  being  separated  by  force,  or  as  the 
result  of  movements  can-ied  beyond  the  normal  range  of  motion  of  the 
joint  involved.  Dislocations  of  the  shoulder,  for  example,  are  usually 
caused  by  indirect  violence,  the  arm  being  hyperabducted.  AYhen  the 
arm  is  hyperabducted  the  upper  end  of  the  humerus  comes  in  contact 
M'ith  the  edge  of  the  acromion,  and  a  new  center  of  motion  is  created 
if  hyperabduction  is  continued.  If  the  long  arm  of  the  lever,  repre- 
sented by  the  part  of  the  extremity  distal  to  the  head  is  still  hyper- 
abducted, the  head  of  the  humerus,  corresponding  to  the  short  arm  of 
the  lever,  is  forced  out  of  the  lower,  weak  portion  of  the  capsule.  Dis- 
locations are  rarely  caused  by  direct  violence. 

Dislocations  are  also  rarely  caused  by  muscular  action.  The  shoul- 
der is  occasionally  dislocated  by  throwing  the  arm  suddenly  backward 
or  in  lifting  a  hea\y  weight.  Many  individuals  can  voluntarily  dislo- 
cate different  joints,  most  commonly  the  first  metacarpo-phalangeal 
joint.  A  joint  may  be  dislocated  in  a  convulsion — for  example,  in 
epilepsy. 

A  habitual  dislocation  is  a  special  form  which  recurs  frequently,  and 
may  be  caused  by  some  insignificant  trauma,  by  voluntary  or  involun- 
tary muscular  action.  This  form  of  dislocation  is  usually  the  result  of 
an  ordinary  traumatic  dislocation  in  which  the  ligaments  were  severely 
lacerated,  or  of  a  paralysis  of  one  or  more  of  the  muscles  about  the 
joint,  or  of  a  fracture  of  one  of  the  bony  prominences  about  the  joint 
which  normally  inhibits  excessive  movements. 

After  the  head  of  a  bone  has  been  forced  out  of  the  capsule  by  tor- 
sion, hyperflexion,  or  hyperextension,  it  may  be  still  further  displaced. 
For  example,  in  dislocation  of  the  shoulder  the  head  of  the  humerus  is 
driven  out  of  the  lower  part  of  the  capsule  by  hyperabduction,  and  is 
then  displaced  forward  beneath  the  eoracoid  processes.  The  secondary 
displacements  are  caused  by  the  continued  action  of  the  force  causing 
the  dislocation,  by  the  weight  of  the  extremity,  by  the  elastic  tension 
of  the  soft  tissues,  and  especially  by  the  ligaments  and  muscles. 

The  nomenclature  of  the  different  varieties  of  dislocation  has  not 
been  definitely  established.  Usually,  however,  the  bone  situated  farthest 
from  the  trunk  or  the  one  which  moves  most  freely  upon  the  other  is 
spoken  of  as  being  dislocated. 

In  speaking  of  a  dislocation  of  the  shoulder,  it  is  described  as  a  dis- 


566  THE   MECHANICAL   INJURIES 

location  of  the  upper  end  of  the  hnmeriis.  The  position  which  the 
bone  occupies  after  the  dislocation  has  occurred,  or  the  direction  in 
which  the  bone  is  displaced,  is  employed  in  describing  a  dislocation ;  for 
example,  one  speaks  of  a  subcoracoid  dislocation  of  the  shoulder,  of 
a  backward  dislocation  of  the  ulna.  This  nomenclature,  however,  does 
not  always  accurately  describe  the  mechanism;  for  example,  in  the  so- 
called  backward  dislocations  of  the  elbow  the  lower  end  of  the  humerus 
is  forced  forward  through  the  rent  in  the  capsule,  in  the  so-called  dorsal 
dislocation  of  the  fingers  the  head  of  the  metacarpal  bone  is  forced  for- 
ward through  the  capsule. 

Pathology  of  Unreduced  Dislocations. — The  pain  and  swelling  soon 
subside,  even  when  the  dislocation  is  not  reduced.  A  limited  amount 
of  motion  returns,  and  the  atrophic  muscles  become  stronger.  Changes 
occur  in  the  articular  cartilages,  which  are  very  similar  to  those  asso- 
ciated with  arthritis  deformans.  The  concave  articular  surfaces  become 
filled  in  with  granulation  tissue.  The  dislocated  end  of  the  bone  rests 
in  a  depression  which  develops  as  the  result  of  pressure,  and  is  sur- 
rounded by  an  acetabulumlike  wall  of  bone  which  is  formed  by  the 
traumatized  periosteum. 

The  scar  tissue  which  forms  surrounds  the  head  of  the  bone  like  a 
new  capsule.  If  the  new  depression  becomes  lined  with  fibrous  carti- 
lage, a  neartlirosis  (which  permits  of  some  motion  unassociated  with 
pain)  develops. 

Symptoms. — The  symptoms  of  a  recent  dislocation  are  severe  pain 
and  more  or  less  complete  impairment  of  function.  To  these  may  be 
added  the  signs  associated  with  changes  in  the  position  of  the  articular 
ends  of  the  bones.  These  differ  greatly,  but  are  quite  characteristic  and 
typical  for  the  different  joints. 

Diagnosis. — In  making  a  diagnosis  of  a  dislocation  the  character  of 
the  trauma,  the  impairment  of  function,  and  the  findings  elicited  by 
inspection,  palpation,  and  the  Roentgen-ray  picture  should  be  considered. 

Inspection  reveals  at  once  a  striking  change  in  the  contour  of  the 
joint  and  in  the  direction  of  the  bones  entering  into  the  formation 
of  the  joint.  The  form  of  the  joint  differs  markedly  from  that  of 
the  sound  side.  Where  normally  there  should  be  a  prominence  will  be 
found  a  depression;  where  there  should  be  a  depression  will  be  found 
a  prominence.  The  direction  of  the  dislocated  bone  is  also  changed. 
The  axis  of  the  bone  no  longer  passes  into  the  articular  cavity,  but 
passes  by  it.  Besides  the  extremity  is  either  shortened  or  lengthened, 
depending  upon  whether  the  end  of  the  bone  rests  a])ove  or  below  the 
rim  of  the  joint  cavity. 

If  there  is  but  little  swelling,  the  liiidings  revealed  by  inspection  may 
be  characteristic  enough  to  make  the  diagnosis  of  a  dislocation  positive. 


MECHANICAL   INJURIES  OF   THE   DIFFERENT  TISSUES  567 

If  so,  palpation,  which  is  often  painful,  may  be  omitted.  If  the  swell- 
ing is  great,  careful  palpation  of  the  bony  prominences  of  the  joint, 
comparing  them  Avith  those  of  the  sound  side,  is  of  great  value.  The 
dislocated  end  of  the  bone  may  be  felt  in  its  abnormal  position  when 
the  shaft  of  the  bone  is  moved,  and  a  depression  may  be  felt  at  the 
position  normally  occupied  by  the  dislocated  bone.  Passive  movements 
will  show  that  the  dislocated  head  is  firmly  held  in  its  abnormal  posi- 
tion by  tension  of  the  muscles  and  ligaments,  and  that  if  the  end  of 
the  bone  is  displaced  from  its  abnormal  position  it  quickly  returns  to 
it  when  traction  is  no  longer  made. 

Co7)iplicaiions. — Fractures  are  the  most  frequent  complications  of 
dislocations.  If  the  line  of  fracture  is  situated  close  to  the  head  of  the 
bone  or  passes  through  the  diaphysis,  the  head  will  no  longer  rotate 
with  the  shaft  and  the  dislocated  part  will  not  be  as  immobile  as  is 
the  case  when  a  dislocation  is  not  complicated  by  a  fracture.  The  sepa- 
ration of  small  fragments  of  bones  to  which  muscles  or  ligaments  are 
attached  may  often  be  recognized  by  crepitus  elicited  when  movements 
are  made.  Clinically  it  is  often  impossible  to  recognize  the  separation 
of  these  small  fragments.  A  diagnosis  can,  however,  be  easily  made  if 
a  Roentgen-ray  examination  is  made. 

One  of  the  bones  of  the  forearm  or  leg  may  be  dislocated,  the  other 
fractured.  Injuries  of  nerves,  blood  vessels,  muscles,  and  tendons  are 
less  connnon  than  fractures.  They  may  be  recognized  by  the  clinical 
symptoms  peculiar  to  them. 

An  old  dislocation  is  less  painful  than  a  recent  one.  Both  active 
and  passive  motions  are  greatly  restricted  in  an  old  dislocation,  and 
crepitus  which  is  caused  by  a  destruction  of  the  articular  cartilages  is 
usually  easily  elicited.  There  may  be  considerable  swelling  of  the  para- 
articular tissue  if  repeated  unsuccessful  attempts  at  reduction  have  been 
made. 

General  Rules  for  tJte  Reduction  of  a  Dislocation. — The  treatment  of 
a  dislocation  consists  of  reduction,  by  which  is  understood  the  replace- 
ment of  the  dislocated  end  of  the  bone  to  its  normal  position.  Although 
the  manipulations  that  must  be  made  in  reducing  a  dislocation  vary  with 
the  different  joints,  there  is  a  general  principle  which  underlies  the  re- 
duction of  all  dislocations.  [Gunn,  of  Chicago,  and  Bigelow,  of  Boston, 
were  the  first  to  suggest,  as  the  result  of  careful  anatomical  studies  and 
clinical  experience,  that  the  untorn  portion  of  the  capsule  offered  the 
main  obstacle  to  reduction.  Gunn  then  enunciated  the  following  rule, 
which  may  be  employed  in  the  reduction  of  any  dislocation :  Relax  the 
untorn  portion  of  the  capsule  by  placing  the  part  in  the  position  it 
occupied  when  the  bone  was  dislocated  and  reverse  the  force.] 

A  dislocation  can  be  more  easily  reduced  if  a  general  anaesthetic  is 


568  THE   MECHANICAL   INJURIES 

given.  The  muscles  of  a  well-developed  individual  contract  so  power- 
fully that  it  is  impossible  to  make  the  necessary  manipulations  unless 
they  are  relaxed.    Laughing  gas  is  to  be  preferred  in  these  cases. 

The  earlier  reduction  is  attempted  the  easier  it  will  be.  The  adhe- 
sions which  form  in  old  cases  must  first  be  broken  up  by  forcible 
manipulations  before  a  reduction  can  be  made. 

After  reduction  has  been  attempted  the  surgeon  should  determine 
whether  the  bone  occupies  its  normal  position  or  not.  If  the  attempt 
at  reduction  has  been  successful,  an  immobilizing  dressing  should  be 
worn  from  eight  to  ten  days.  After  this  time  repair  has  advanced  far 
enough  to  permit  of  massage  and  gentle  active  and  passive  motion.  The 
movements  which  caused  the  dislocation  should  not  be  attempted  for 
some  time,  for  the  capsule  may  be  stretched  and  torn  again. 

The  function  of  the  joint  is  soon  restored  after  early  reduction  of 
a  simple  dislocation.  Functional  disturbances  may  persist  for  a  long 
time  if  fragments  of  bone  have  been  separated,  or  if  a  large  amount 
of  blood  which  is  absorbed  slowly  is  poured  out  into  the  soft  tissues. 

Conditions  Rendering  Bloodless  Eediiction  Difficult  or  Impossible. — 
Bloodless  reduction  may  be  very  difficult  or  impossible  if  the  rent  in 
the  capsule  is  small  and  the  capsule  surrounds  tightly  the  dislocated 
bone,  or  if  a  tendon  (in  dorsal  dislocations  of  the  thumb)  or  a  piece  of 
the  capsule  with  or  without  a  fragment  of  bone  (in  dislocations  of  the 
humerus)  becomes  incarcerated  between  the  dislocated  bone  and  the  one 
with  which  it  articulates. 

Reduction  by  the  Open  Method. — In  these  cases  it  may  be  necessary 
to  expose  the  joint  by  an  open  operation  in  order  to  remove  the  obstacle 
to  reduction.  An  operation  must  also  be  performed  in  old  dislocations 
which  can  no  longer  be  reduced  by  the  ordinary  manipulation.  The 
capsule  must  then  be  opened,  the  scar  tissue  removed  from  the  joint 
cavity,  adhesions  separated,  and  the  dislocated  bone  returned  to  its  nor- 
mal position.  The  earlier  a  reduction  by  the  open  method  is  attempted 
in  these  cases  the  better  the  functional  results  will  be. 

Reduction  of  a  Dislocation  Complicated  by  a  Fracture. — It  may  be 
very  difficult  to  reduce  a  dislocation  complicated  by  a  fracture.  A  dis- 
location complicated  by  the  separation  of  a  small  fragment  of  bone,  a 
tubercle,  or  tuberosity  can  often  be  reduced  relatively  easily,  j:)rovided 
the  piece  of  bone  does  not  become  incarcerated.  But  if  the  fracture  is 
situated  near  the  dislocated  end  of  the  bone  or  involves  the  diaphysis, 
it  is  only  rarely  that  the  dislocation  can  be  reduced  by  the  ordinary 
manipulation  and  direct  pressure  over  the  dislocated  end  of  the  bone. 
Then  reduction  by  the  open  method  is  indicated,  the  fracture  being 
wired  at  the  same  time.  In  these  cases  it  is  poor  surgery  to  postpone 
the  attempts  at  reduction  until  the  fracture  has  united,  for  then  at- 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  569 

tempts  at  reduction  are  often  unsuccessful,  the  bone  is  freciuently  re- 
fractured,  and  the  function  of  the  joint  is  restored  slowly,  if  at  all. 
In  old  dislocations  with  poor  functional  results  resection  of  the  head 
of  the  bone  may  be  indicated. 

(b)  OPEN    INJURIES    OF    JOINTS 

Any  kind  of  a  wound  may  involve  the  capsule  of  a  joint  and  open 
the  joint  cavity.  A  number  of  different  foreign  bodies,  such  as  bullets, 
fragments  of  shells,  needles,  nails,  pieces  of  metal,  wood,  and  stone,  may 
penetrate  a  joint  cavity. 

The  symptoms  and  clinical  course  of  such  an  injury  depend  upon 
the  size  of  the  wound  and  whether  or  not  infection  develops.  Infection 
is  the  greatest  danger  associated  with  wounds  of  this  character. 

The  opening  in  the  joint  produced  by  foreign  bodies,  punctured 
and  gunshot  wounds  is  usually  small,  and  the  most  important  diagnostic 
sign  of  an  injury  of  joint — the  discharge  of  synovial  fluid — is  fre- 
quently wanting.  This  is  due  to  the  fact  that  the  wound  may  be  closed 
by  a  blood  clot  or  by  a  change  in  the  position  of  the  different  tissues 
when  the  limb  is  moved.  The  position  of  the  wound  in  the  skin,  the 
character  of  the  injury,  or  the  development  of  an  exudate  in  the  joint 
may  be  the  only  clew  to  an  injury  of  this  kind.  A  probe  should  never 
be  used  to  determine  whether  a  wound  extends  into  a  joint  cavity  or 
not,  for  the  dangers  of  introducing  a  secondary  infection  in  this  way 
are  great. 

The  swelling  of  a  joint  which  develops  immediately  after  a  wound, 
especially  a  gunshot  wound,  is  due  to  hipmorrhage;  occasionally  to  the 
introduction  of  air.  The  swelling  which  develops  later  is  due  to  in- 
flammation. If  the  latter  is  caased  by  pyogenic  or  putrefactive  bac- 
teria severe  local  and  general  symptoms  develop. 

Most  of  the  small  wounds  involving  joints  heal  without  complica- 
tions if,  after  the  area  surrounding  the  wound  in  the  skin  has  been 
carefully  sterilized,  a  dressing  of  iodoform  or  dry  aseptic  gauz(>  is  ap- 
plied and  the  part  is  immobilized  in  a  circidar  or  molded  i)laster-of-Paris 
dressing.  It  was  shown  by  von  Bergmann  in  the  Russo-Turkish  war  that 
a  foreign  body  may  become  encapsulated  in  a  joint  Avithout  causing 
infection  if  this  conservative  treatment  is  followed,  and  no  second- 
ary infection  is  introduced  by  attempting  to  locate  the  bullet  by  prob- 
ing or  by  the  introduction  of  special  instruments.  Aspiration  is  indi- 
cated if  an  exudate  accompani(Ml  by  mild  symptoms  develops.  If  the 
exudate  is  purulent  the  joint  should  be  opened  and  drained.  If  a  viru- 
lent suppurative  or  putrefactive  inflammation  develops,  the  joint  should 
be  opened  widely,  or  resected,  or  an  amputation  performed,  depending 
upon  indications. 


570  THE  MECHANICAL  INJURIES 

Penetrating  foreign  bodies  (such  as  a  splinter  of  wood,  nail,  or 
needle)  should  be  removed  innnediately  if  they  have  rough  or  rusty 
surfaces,  for  clinical  experience  has  shown  that  such  bodies,  when  al- 
lowed to  remain,  are  often  followed  by  infection.  Foreign  bodies  which 
irritate  the  synovial  membrane,  causing  serous  synovitis,  or  give  rise  to 
the  symptoms  associated  with  a  free  body  should  be  removed,  even  if 
the  wound  has  repaired  completely  without  infection.  Their  position 
should  be  determined  before  an  operation  is  undertaken  by  palpation 
and  Roentgen-ray  examinations,  then  but  a  small  incision  of  the  capsule 
is  required  for  removal  of  the  body.  An  immobilizing  dressing  should 
be  worn  for  two  weeks  after  such  an  operation. 

Broad  gaping  wounds  of  joints  are  easily  recognized.  They  are  most 
frequently  associated  with  incised  and  contused  wounds  (such  as  are 
caused  by  knives,  sabers,  and  scythes),  and  with  crushing  injuries  and 
lacerated  wounds,  such  as  are  caused  by  the  explosion  of  a  bomb,  the 
explosion  of  a  boiler,  by  machines,  and  by  wild  animals. 

Of  these,  the  clean-cut,  incised  wounds  heal  most  readily.  If  they 
are  seen  early  the  wounds  in  the  capsule  and  skin  should  be  sutured. 
Old  cases  of  this  character  should  be  treated  by  the  open  method,  and 
when  the  conditions  become  favorable  secondary  suture  of  the  wounds 
should  be  performed. 

Compound  Dislocations. — Contused  and  lacerated  wounds  of  joints 
may  be  associated  with  a  dislocation.  Compound  dislocations  are  usu- 
ally the  result  of  great  violence,  the  dislocated  end  of  the  bone  being 
driven  through  the  capsule  surrounding  it  and  the  soft  tissues  over  it. 
In  other  cases  the  destruction  of  the  capsule  is  so  extensive  that  the 
bone  is  displaced  by  its  own  weight.  Complicating  injuries  of  all  kinds 
of  the  bones,  nerves,  blood  vessels,  muscles,  and  tendons  may  be  asso- 
ciated with  compound  dislocations  and  those  produced  by  great  vio- 
lence. In  some  cases  strips  and  shreds  of  skin  form  the  only  connection 
between  the  dislocated  part  and  the  body. 

The  first  indications  in  the  treatment  of  a  compound  dislocation  are 
to  prevent  infection  and  to  favor  wound  repair.  After  these  indications 
have  been  met,  the  dislocation  should  be  reduced.  The  wound  should 
then  be  treated  by  the  open  method,  and  the  part  immobilized  by  a 
molded  or  fenestrated  plaster-of-Paris  dressing. 

Favorable  cases  recover  with  ])ut  slight  impairment  of  function. 
Severe  infections  which  may  demand  incision  or  resection  of  the  joint, 
or  amputation  of  the  extremity,  not  infrequently  develop. 

Literature. — Barth.  Zur  Lehre  von  den  freien  Gelenkkorpern.  Chir.  Konjir.- 
Verhandl.,  1896,  I,  p.  31; — Die  Entstehung  und  das  Wachstum  her  freien  Gelenk- 
korper.  Arch.  f.  klin.  Chir.,  Bd.  56,  1898,  p.  507. — Boerner.  Klin.  u.  pathol.-ana- 
tom.  Bcitriige  zvir  Tiohre  von  don  r.olcnkinausen.     Deutsche  Zeitschrift  f.  Chir.,  Bd. 


MECHANICAL   INJURIES   OF   THE    DIFFERENT   TISSUES  571 

70,  1903. — H.  Braun.  Untersuchungen  iiber  den  Bau  der  Synovialmembranen  und 
Gelenkknorpel,  sowie  iiber  die  Resorption  fliissiger  und  fester  Kiirper  aiis  den  Gelenk- 
hohlen.  Deutsche  Zeitschr.  f.  Chir.,  Btl.  39,  1894,  p.  35. — van  Hassel.  Du  traitemcnt 
des  traumatismes  articulaires.  Journal  de  chir.  et  ann.  de  la  see.  beige  de  chir.,  1901, 
No.  6. — Hildebrand.  Experiment.  Beitrag  zur  Lehre  von  den  freien  Gelenkkorpern. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  42,  p.  292,  1890. — Jaffe.  Ueber  die  Veranderungen  der 
Synoviahnembran  bei  Beriihrung  niit  Blut.  Arch.  f.  klin.  Chir.,  Bd.  54,  1896. — Kronlcin. 
Die  Lehre  von  den  Luxationen.  Deutsche  Chir.,  1882. — Pagenstccher.  Die  isolicrte 
Zerreissung  der  Kreuzbander  des  Kniese.  Deutsche  med.  Wochenschr.,  1903,  No.  47. — 
Riedel.  Ueber  das  Verhalten  von  Blut,  sowie  von  indifferenten  und  differentcn  Freind- 
korpern  in  den  Gelenken.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  12,  1879,  p.  447. — Schlatter. 
Mcniskusluxationen.  Beitr.  z.  klin.  Chir.,  Bd.  41,  1904,  p.  229. — Schmieden.  Ein 
Beitrag  zur  Lehre  von  den  Gelenkmausen.  Arch.  f.  klin.  Chir.,  Bd.  62,  1901,  und 
Arbeiten  aus  v.  Bergmanns  Klinik  15,  p.  209. — v.  Volkmann.  Die  Krankheiten  der 
Bewegungsorgane  in  v.  Pithas  und  Billroths  Handb.  d.  Chir.  Erlangen,  1872,  Bd.  2, 
Abt.  2,  p.  618. — Vollbrecht.  Umschriebene  Binnenverletzungen  des  Kniegelenkes. 
Beitr.  z.  klin.  Chir.,  Bd.  21,  1898,  p.  216. 

IX.     INJURIES   OF   THE   OSSEOUS   SYSTEM 
(a)  SUBCUTANEOUS   INJURIES   OF    BONES    AND    CARTILAGE 

The  results  of  the  action  of  direct  and  indirect  violence  upon  the 
osseous  system  dififer  widely,  depending  upon  the  character  and  the  de- 
gree of  the  trauma.  Slight  changes,  such  as  ha?morrhage  beneath  the 
periosteum,  into  the  bone  marrow,  or  spongiosa,  may  occur  alone,  or 
accompany  the  severer  forms  of  fractures. 

Subperiosteal  Haematoma. — A  subperiosteal  h{vmatoma  may  follow 
contusions  or  lacerations  of  the  periosteum  produced  by  muscular  action 
or  the  displacement  of  the  soft  tissues,  as  the  blood  vessels  entering  the 
cortex  may  be  torn  in  these  ways.  A  painful,  fluctuating  swelling 
varying  in  size  is  caused  by  the  accumulation  of  blood  between  the 
bone  and  periosteum.  The  so-called  cephalJuBmatoma,  occurring  so  fre- 
(juently  over  the  one  or  the  other  of  the  parietal  bones  of  the  newborn, 
follows  laceration  of  the  periosteal  vessels  produced  by  the  displace- 
ment of  the  scalp  and  the  bones  of  the  skull  during  labor.  Traumatic 
separation  of  the  perichondrium  of  the  cartilages  of  the  ear  gives  rise 
to  a  cystic  swelling  known  as  an  otluvmatoma.  The  blood  extravasated 
in  these  cases  remains  fluid,  and  frecjuently  it  is  not  absorbed  for  a  long 
time.  The  loosened  periosteum  proliferates  at  its  points  of  attachment 
to  the  bone  to  form  a  thin  wall  of  bone  which  surrounds  the  fluid  blood 
like  a  wall.  Occasionally  the  proliferation  is  still  more  extensive,  and 
an  entire  piece  of  loosened  periosteum  becomes  transformed  into  a  thin 
scale  of  bone.  Irregularities  in  the  surface  of  the  bone  resulting  from 
a  proliferation  of  the  periosteum  may  persist  after  the  absorption .  of 
small  extravasations  of  blood.  These  are  quite  common  upon  the  ante- 
rior surface  of  the  tibia. 


572  THE   MECHANICAL   INJURIES 

Compression  secured  by  a  bandage  evenly  and  firmly  applied  imme- 
diately after  the  injury  and  aspiration  of  the  fluid  blood  are  impor- 
tant factors  in  the  successful  treatment  of  these  haematomas. 

Haemorrhages  into  the  Bone  Marrow. — Punctate  hasmorrhages  into 
the  bone  marrow  follow  concussions  and  accompany  all  fractures  in- 
volving the  larger  bones.  It  has  been  demonstrated  by  the  experi- 
mental studies  of  suppurative  osteomyelitis  that  such  hemorrhages  favor 
the  deposition  of  bacteria  from  the  blood  stream.  Further  than  this 
these  hgemorrhages  have  no  surgical  significance. 

Hjemorrhages,  even  when  slight,  and  crushing  injuries  of  the  lamelhu 
may  be  followed  by  changes  which  may  alter  the  form  of  the  bones 
involved,  and  thus  be  the  source  of  serious  trouble  (for  example,  changes 
in  the  form  of  the  neck  of  the  femur  and  of  the  vertebra?).  An  osteitis 
ending  in  sclerotic  changes  or  a  rarefying  osteitis  ending  in  atrophy 
may  follow  the  development  of  granulation  tissue  resulting  from  such 
injuries. 

Simple  Fractures 

By  the  term  fracture,  in  the  surgical  sense  of  the  word,  is  meant  the 
breaking  of  a  bone  or  cartilage.  A  fracture  may  be  complete  or  incom- 
plete, depending  upon  whether  the  bone  is  divided  into  two  or  more 
distinct  fragments  or  not.  A  complete  fracture  is  one  in  which  the 
bone  is  divided  into  two  or  more  distinct  fragments  by  a  line  of  fracture 
crossing  its  long  axis.  Fissures,  "  green-stick  "  fractures  or  infrac- 
tions, the  separation  of  a  splinter  of  bone,  or  of  an  apophysis  are  clas- 
sified as  incomplete  fractures. 

Traumatic  are  differentiated  from  pathological  fractures  in  which 
the  resistance  of  the  bone  has  been  reduced  by  some  inflammatory 
process  (osteomyelitis,  tuberculosis,  syphilis),  by  tumors  (sarcoma,  car- 
cinoma, enchondroma,  cysts),  or  by  some  general  disease  (rickets, 
osteomalacia,  scurvy,  atrophy  associated  with  paralysis,  tabes,  syringo- 
myelia, etc.). 

Fissures. — Fissured  fractures  are  characterized  by  a  split  or  crack 
in  the  bone  which  does  not  entirely  circumscribe  the  fragment  and  does 
not  separate  it  from  the  remainder  of  the  bone.  Fissures  penetrate  the 
bone  involved  in  different  directions  and  to  different  depths  without 
altering  its  outline,  as  its  continuity  is  maintained.  The  periosteum 
may  remain  intact  or  be  elevated  by  an  extravasation  of  blood,  or  torn. 
Aside  from  the  tenderness  and  swelling  following  the  development  of 
the  ha'matoma.  th(>re  are  no  special  symptoms.  The  diagnosis  cannot 
be  made  witli  certainty  except  when  the  bon(»  is  exposed  to  direct  ex- 
amination. 'I'he  larger  fissures  can,  however,  be  distinctly  seen  in 
Roentgen-ray  pictures. 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  573 

Infractions. — An  infraction  or  "  grern-stick  "  fracture  is  cliarac- 
terized  by  the  fracture  involvin*?  a  portion  of  the  thickness  of  a  long 
bone,  combined  with  a  bending  of  the  bone  at  the  seat  of  fracture. 
It  occurs  most  frequently  in  the  costal  cartilages  and  in  the  soft, 
yielding  bones  of  children,  especially  those  suffering  with  rickets.  In 
this  form  of  fracture  the  periosteum  may  remain  intact  or  be  torn  at 
the  seat  of  fracture.  The  integrity  of  the  cortical  layer  of  bone  oppo- 
site the  fracture  is  maintained. 

Complete  Fractures. — Complete  fractures  are  caused  by  violence 
which  exceeds  the  limits  of  elasticity  and  resistance  of  the  bones  upon 
which  it  acts.  They  may  be  produced  by  the  contraction  of  powerful 
nuiscles,  by  a  pull  upon  ligaments  attached  to  the  bone,  or  by  direct  or 
indirect  violence. 

The  fracture  may  occur  at  the  point  of  application  of  the  force,  or 
the  force  may  be  transferred  along  an  extremity  which  is  held  rigid  by 
muscular  contraction  or  because  of  anatomical  relations,  and  a  bone  some 
distance  from  the  point  of  application  of  the  force  may  then  be  frac- 
tured. Fracture  of  the  clavicle  by  a  fall  upon  the  extended  hand  is  an 
example  of  a  fracture  by  indirect  violence. 

In  considering  the  mechanism  of  a  fracture,  it  will  be  readily  seen 
that  the  force  producing  the  fracture  must  overcome  the  elasticity  of 
the  bone  and  its  resistance  to  bending  (bending  fractures)  and  torsion 
(torsion  fractures),  and  its  resistance  to  pressure  (compression  frac- 
tures)  and  pull   (tearing  fractures). 

The  resistance  which  the  different  bones  offer  to  violence  varies. 
The  different  forms  of  fractures  depend  upon  the  direction  of  the  line 
of  fracture  and  the  mechanism  by  which  they  are  produced.  Fractures 
are  classified  as  transverse,  oblicpie,  splintered,  spiral,  V-,  T-,  or  Y- 
shaped,  dentate,  longitudinal,  and  comminuted,  depending  upon  the 
direction  of  the  line  or  lines  of  fracture.  Depending  upon  the  seat  of 
fracture,  they  are  spoken  of  as  fracture  of  the  shaft  of  the  bone,  sepa- 
rati(m  of  the  epiphysis,  and  as  intra-articular  or  articular.  Depending 
upon  the  mechanism  by  which  they  are  produced,  the  following  classi- 
fication is  made  (von  Bruns,  ITelferich)  : 

Bending  fractures  of  long  bones  may  be  produced  by  direct  or  indi- 
rect force.  If  the  force  acts  at  right  angles  to  the  long  axis  of  the  bone, 
the  latter  is  bent  and  broken  like  a  green  or  tougli  stick  when  bent  over 
the  knee.  If  the  force  acts  upon  the  long  axis  of  the  bone,  the  natural 
curves  of  the  bone  (for  example,  of  the  neck  of  the  femur)  become  con- 
siderably exaggerated.  Bending  fi-actures  are  often  characterized  by 
the  separation  of  a  wedge-shaped  piece  of  bone,  the  base  of  which  always 
lies  upon  the  concave  side  of  the  fracture.  If  this  wedge-shaped  piece 
is  not  completely  separated  an  oblique  fracture,  combined  with  a  fissure 


574 


THE  MECHANICAL   INJURIES 


Ih, 


of  oue  fragment,  is  produced.     In  transverse  fractures  by  bending  the 
fissures  in  the  bone  may  correspond  to  the  form  of  a  wedge. 

Fissures  and  "  green-stick  fissures  "  may  also  be  produced  by  this 
same  mechanism  of  excessive  bending. 

The  flexion  fracture  is  very  closely  related  to  the  fracture  by  bend- 
ing.   In  this  form  one  end  of  the  bone  is  forcibly  moved  while  the  other 

end  is  held  rigid.  Bones  are 
broken  by  this  mechanism  with 
the  osteoclast,  the  fracture  being 
produced  at  the  point  of  fixation 
of  the  bone.  Fracture  of  the 
olecranon  by  overextension  of  the 
forearm  is  another  example  of  a 
Fracture  of  this  kind. 

Compression  or  crusliing  frac- 
tures are  produced  in  long  bones 
by  force  acting  in  the  long  axis 
of  the  bone,  the  end  of  the  diaph- 
ysis  being  driven  into  the  broader 
and  less  resistant  spongy  mass 
of  the  metaphysis  and  epiphysis. 
Infractions  then  occur  or  the 
fractured  ends  become  impacted. 
These  fractures  are  most  common  in  the  neck  of  the  femur  following 
a  fall  upon  the  trochanter ;  in  the  upper  end  of  the  humerus  and  tibia 
following  falls  upon  the  elbow  and  foot  respectively.  Crushing  frac- 
tures of  the  bodies  of  the  vertebrae  and  of  the  os  calcis  may  be  produced 
by  falls  from  a  considerable  height. 

Fractures  hy  crusliing  off'  occur  when  the  projecting  points  of  ap- 
posed articular  surfaces  are  forcibly  moved  by  each  other.  One  of  the 
best  examples  of  this  form  is  fracture  of  the  coronoid  process  occurring 
in  backM'ard  dislocations  of  both  bones  of  the  forearm. 

Avulsion  of  an  apophysis  or  a  scale  of  hone,  or  a  fracture  involving 
one  of  the  larger  bones,  may  be  produced  by  miiscular  action,  or  a  severe 
pull  upon  a  tendon  or  ligament  attached  to  the  bone.  These  fractures 
are  frequently  associated  with  dislocations.  They  occur  most  frequently 
in  the  typical  Pott's  and  Colles's  fractures,  and  in  fractures  of  the 
olecranon  and  patella  produced  by  muscular  action. 

Torsion  fractures  are  produced  by  the  forcible  twisting  of  a  bone 
when  one  of  its  extremities  is  held  rigid.  A  bending  of  the  bone  is 
often  a  contributing  factor  in  this  form  of  fracture.  The  line  of  frac- 
ture runs  in  the  form  of  a  spiral,  corresponding  to  the  direction  in 
which  the  bone  has  been  twisted.     The  fragments  of  bone  are  pointed 


a  b  c 

Fig.  224. — Different  Forms  of  Bending 
Fractures,  a,  Oblique  fracture;  h,  trans- 
verse fracture  with  fissures;  c,  oblique  frac- 
ture with  separation  of  a  cuneiform  frag- 
ment.     (After  Helferich.) 


MECHANICAL    INJURIES   OF   TIU:    DIFFERENT  TISSUES  575 


and  very  easily  penetrate  the  skin.     Large  screw-shaped  fi-agnients  are 
frequently  separated  in  this  form  of  fractures   (von  Bruns,  Fig.  225). 
The  most  common  causes  of  torsion  fractures  ai*e  twistin*;-  of  the  body 
while  the  extremities  are 
held    fast,    and    injuries 
inflicted   by   the   driving 
wheels  of  engines. 

Comminuted  fractures 
are  produced  by  great 
violence.  They  occur 
most  frequently  in  ma- 
chine injuries,  the  bone 
being  splintered  into  a 
munber  of  fragments  or 
crushed.  They  resemble 
closely  fractures  pro- 
duced by  projectiles. 

Injuries  of  the  Soft 
Tissues,  Viscera,  and 
Nerves. — Injuries  of  the 
soft  tissues,  viscera,  and 
nerves  may  be  caused  by 
the  force  producing  the 
fracture  or  by  the  dis- 
placement of  the  bony 
fragments.  Fractures  by 
direct  violence  are  ac- 
companied by  contusions 
of  the  skin  and  soft  tis- 
sues, and  for  this  reason 
larger  ha^nuitomas  devel- 
op   in    fractures    caused 

by  direct  violence  than  in  those  caused  by  indirect  violence.  In  frac- 
tures by  indirect  violence,  especially  in  fractures  by  bending  and  tor- 
sion, the  displaced  fragments  may  injure  the  larger  blood  vessels  and 
nerves,  may  penetrate  and  perforate  the  soft  tissues,  a  simple  fracture 
then  becoming  compound.  In  comminuted  fractures  the  injury  to  the 
soft  tissues  may  be  very  great,  as  the  fragments  may  l)e  forcibly  driven 
into  the  surrounding  tissues.  The  brain  and  spinal  cord  may  be  injured 
in  fractures  of  the  skull  and  vertebra'  respectively;  laceration  of  the 
urethra  or  bladder  may  be  associated  witli  fractures  of  the  ])elvic  bojies; 
contusion  and  laceration  of  the  nnisculospiral  nerve  with  fractures 
through  the  middle  of  the  humerus. 


Yic.  '22:>. — Si'inAL  Fracture  of  thk  I'K.Miui  ■with  a 
Typical  Screw-shaped  Fragment,  (von  Bergmann's 
"  Handbook  of  Practical  Surgery.") 


576  THE   MECHANICAL   INJURIES 

Kelative  Frequency  ivitli  whicli  Different  Bones  are  Fractured. — 
The  statistics  of  von  Brans  are  of  value  in  showing  the  relative  frequency 
with  which  different  bones  are  fractured.  According  to  his  statistics, 
fractures  form  more  than  one  seventh  of  all  injuries  reporting  for 
treatment.  Bones  of  the  extremities  are  more  freciuently  fractured 
than  are  those  of  the  head  and  trunk,  fractures  of  the  bones  of  the 
upper  extremity  being  more  common  than  th(!se  of  the  lower  extremity. 
Fractures  of  the  bones  of  the  forearm  are  most  conmion,  forming  18 
per  cent  of  fractures ;  then  follow  those  of  the  bones  of  the  legs,  ribs, 
and  clavicle,  forming  from  15  to  16  per  cent.  Fractures  of  the  bones  of 
the  hand  form  11  per  cent;  of  the  humerus,  7  per  cent;  of  the  femur, 
6  per  cent;  of  the  bones  of  the  foot,  2.6  per  cent;  of  the  bones  of  the 
face,  2.4  per  cent;  of  the  skull,  1.4  per  cent;  of  the  scapula,  vertebra, 
and  pelvis,  1  jier  cent;  and  of  the  sternum,  0.1  per  cent  of  all  frac- 
tures. Fractures  are  four  and  a  half  times  more  common  in  the  male 
than  in  the  female  sex. 

Age  at  which  Fractures  are  Most  Common. — The  greatest  number  of 
fractures  occur  in  the  third  deceiniium.  The  frequency  of  fractures 
gradually  increases  from  the  tenth  to  the  fortieth  years,  and  then 
decreases.  Still  the  frecjuency  is  greater  in  the  eighth  and  ninth  decennia 
than  in  the  first  and  second.  Fractures  occurring  at  birth  should,  of 
course,  be  included  in  the  first  decennium. 

Symptoms. -^The  symptoms  of  a  simple  fracture  are  subjective  and 
objective.  The  former  consist  of  pain  at  the  point  of  fracture  and 
impaired  function,  varying  from  slight  to  complete  disability.  The 
interference  with  function  is  due  in  part  to  pain  w^hich  is  intensified  by 
movement,  in  part  to  loss  of  the  support  afforded  when  the  bone  or  bones 
are  intact.  The  most  striking  objective  symptom  is  a  deformity  which  is 
due  to  alteration  in  the  shape  of  the  bone  and  to  displacement  of  the  frag- 
ments. The  deformity  may  be  masked  by  an  extravasation  of  blood,  or 
may  be  entirely  wanting  if  the  fragments  are  not  displaced.  The  second 
important  objective  symptom  which  can  be  determined  in  fractures  which 
are  complete  and  are  not  impacted  is  a  false  point  of  motion.  AVhen  the 
fractured  ends  are  manipulated,  crepitus  can  be  elicited  at  this  point. 

The  character  and  the  extent  of  the  displacement  of  the  fractured  ends 
depend  upon  the  continuance  of  the  force  producing  the  fracture,  upon  the 
weight  of  the  part  of  the  extremity  distal  to  the  fracture,  upon  muscular 
action,  and  upon  the  tension  of  the  soft  tissues.  For  example,  in  Colles's 
fracture,  which  is  produced  by  a  fall  upon  the  pnlm  of  the  hand,  the 
lower  fragnHMit  is  displaced  backward  and  upward  by  the  force  produc- 
iiiu  1lit'  I'ljicliirc,  wliilc  ill  I'ljictures  of  the  clavicle  the  acromial  fragment 
is  disj)hi(M'd  downward  and  forward  by  the  weight  of  the  arm,  and  the 
clavicular  fragment  is  drawn  upward  by  the  sterno-cleido-mastoid  muscle. 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  577 

The  following  table,  taken  from  Stimson's  "  Fractui-os  and  Disloca- 
tions," is  very  valuable  in  showing  the  relative  frequency  of  fractures 
of  the  different  bones : 

Hudson  Street  Hospital,  New  York:   Statistics  of  Fractures  Treated  in 
Hospital  and  Dispensary,  1894-1903 


Cases 


Cranium 

Malar  bone 

Nasal  bones 

Superior  maxilla. 
Inferior  maxilla. , 

Zygoma 

Hyoitl 

Spine 

Pelvis 

Coccyx 

Sternum 

Ribs 


"  Upper  extremity" 

Clavicle 

Scapula 

Humerus,  shaft  and  neck 

lower  end 

internal  epicondyle 

Radius  and  ulna 

Radius,  shaft 

CoUes's 

Ulna,  shaft 

olecranon 

Carpus 

Metacarpus 

Phalanges 

Femur 

Patella 

Tibia,  or  tibia  and  fibula 

Abduction  and  adduction  fractures  at  ankle . 

Fibula 

External  malleolus 

Internal  malleolus 

Tarsus 

Metatarsus 

Toes 


Head. 


on 

16 
571 

35 
415 

23 
3j 

62 

65 

3  y     Trunk 

8 

1,396  J 

132 

534 

61 
325 
179 
6 
223 
316 
1,007 
272 
102 

14 
873 
1,737  J 
422 
154 
764 
907 
169 

27 

23 
136 
255 
279 


Cases 

577 


Per  cent 
4.78 


Face  and  Neck       1,063         8 .  65 


1,534       12.68 


ITpper extremity   5,781       47.89 


„  y  Lower  extremity   3,136         25.98 


Total 12,091 


Different  Forms  of  Displacement. — Some  forms  of  displacement  are 
more  connnon  than  others.     Four  principal  forms  are  recognized : 

1.  Angular  displacement  is  produced  by  the  fracturing  violence. 
Subse(inently  it  is  often  increased  by  the  weight  of  the  part  distal  to 


578  THE   MECHANICAL   INJURIES 

the  seat  of  fracture,  by  contraction  of  the  muscles  when  the  patient 
attempts  to  move,  and  by  other  influences,  such  as  spasmodic  muscular 
contractions,  when  the  parts  are  improperly  immobilized.  As  a  result 
of  the  action  of  one  or  more  of  the  factors  above  mentioned  an  angular 
displacement  may  be  transformed  into  one  of  the  other  varieties  about 
to  be  mentioned. 

2.  Lateral  displacement  may  take  place  forward,  backward,  or  to 
either  side,  and  may  be  partial  or  complete.  The  pure  form  of  lateral 
displacement  is  rare  and  occurs  only  in  transverse  fractures.  It  is  usu- 
ally associated  with  overriding  or  angular  displacement,  or  both. 

3.  Displacement  in  the  longitudinal  axis  may  be  associated  with 
shortening  or  lengthening  of  the  extremity,  depending  upon  whether 
the  ends  of  the  bones  override  or  are  separated  by  muscular  action.  In 
fractures  through  the  diaphysis  shortening  is  marked,  especially  in 
oblique  and  comminuted  fractures,  as  the  distal  fragment  is  drawn 
upward  by  the  muscles  arising  from  bones  above  the  seat  of  the  frac- 
ture. Wide  separation  of  the  fragments  may  be  produced  by  contrac- 
tion of  muscles  attached  to  the  proximal  fragment.  The  most  striking 
example  of  wide  separation  of  fragments  is  seen  in  fractures  of  the 
olecranon  process  and  patella. 

4.  Rotatory  displacements  usually  occur  in  torsion  fractures,  and  are 
caused  by  the  fracturing  violence  or  by  some  secondary  factor,  most 
frequently  to  the  weight  of  the  extremity  distal  to  the  line  of  fracture. 
In  fractures  of  both  bones  of  the  leg  the  internal  malleolus  may  be 
directed  forward  or  even  outward,  while  the  patella  occupies  its  normal 
position. 

Displacement  of  the  fractured  ends  in  a  transverse  axis  occurs  in 
fractures  of  the  head  of  the  humerus  and  patella. 

5.  Irregular  displacements,  such  as  occur  in  comminuted  fractures 
and  in  bursting  and  depressed  fractures  of  the  skull  and  facial  bones, 
should  also  be  mentioned. 

Diagnosis. — In  making  a  diagnosis  of  even  a  simple  fracture,  a  defi- 
nite line  of  procedure  should  be  followed. 

History  of  Accident,  Pain,  Impairment  of  Function. — The  history 
of  the  accident  and  a  description  of  the  direction  in  which  the  force 
was  applied  or  the  blow  delivered  niay  give  a  clew  to  the  diagnosis. 
Pain  at  the  seat  of  fracture,  and  impairment  of  function,  when  attempts 
at  movement  are  made,  are  suggestive  but  not  conclusive,  as  simi- 
hir  symptoms  are  fre(|U(>ntly  associated  with  injuri(>s  of  tendons  and 
nerves.  Whether  the  impairment  of  function  is  caused  by  a  contusion, 
a,  s|»i-aii),  a  lissui'cd  fracture,  or,  if  the  loss  of  function  is  complete,  by 
a  dislocation  must  be  deter-iiiined  by  a  more  careful  and  exhaustive 
cxaininatiou. 


MECHANICAL   INJURIES  OF  THE   DIFFERENT  TISSUES  579 

Inspccttun. — Iii  making  au  exaniiiiation  the  injured  part  slioukl  tirst 
be  inspected  and  compared  with  the  uninjured  one,  for  frequently  in 
typical  fractures  the  findings  revealed  by  inspection  are  so  character- 
istic that  there  is  but  little  need  for  manipulations  which  are  often 
painful.  A  deformity,  even  when  slight,  will  be  apparent  to  the  eye 
of  a  trained  surgeon  if  the  contour  of  the  injured  side  is  compared 
with  that  of  the  uninjured  one.  The  deformity  frequently  becomes 
more  pronounced  when  attempts  at  movement  are  made.  If  the  injured 
part  is  greatly  swollen  and  the  deformity  therefore  masked,  shortening 
of  the  extremity  determined  by  use  of  the  tape  measure  and  the  findings 
elicited  by  gentle  manipulation  are  of  great  diagnostic  value. 

Paljjation. — The  diagnosis  of  a  fracture  can  be  made  and  the  relative 
position  of  the  fractured  ends  determined  by  palpation  in  most  cases. 
If  the  finger  is  passed  over  the  surface  of  a  bone,  a  depression  or  fissure, 
or  perhaps  merely  a  loss  of  resistance,  which  indicates  the  position  of 
the  fracture,  can  be  determined.  Exquisite  pain  is  usually  elicited  when 
pressure  is  made  at  the  seat  of  fracture.  This  localized  tenderness  is 
an  important  diagnostic  sign.  If  an  articular  end  of  a  bone  has  been 
fractured  and  displaced,  the  end  can  usually  be  felt  in  a  false  posi- 
tion, and  it  can  no  longer  be  palpated  in  the  position  it  ordinarily 
occupies. 

Fidsc  Point  of  Motion  and  Crepitus. — After  inspection  and  palpa- 
tion, an  attempt  maj'  next  be  made  to  determine  whether  or  not  a  false 
point  of  motion  exists  at  the  seat  of  deformity,  or,  if  there  is  no  deform- 
ity, at  the  point  of  tenderness.  In  eliciting  a  false  point  of  motion,  the 
part  of  the  extremity  distal  to  the  fracture  should  be  grasped  and 
gentle  traction  made,  while  the  proximal  part  is  supported.  The  distal 
part  is  then  either  gently  rotated  or  moved  to  and  fro  to  determine 
whether  or  not  a  false  point  of  motion  exists.  A  false  point  of  motion 
cannot  be  determined  in  impacted  and  green-stick  fractures  unless  more 
force  than  is  usually  warrantable  is  employed.  In  determining  whether 
or  not  there  is  a  false  point  of  motion  in  suspected  fractures  of  the 
upper  part  of  the  femur  and  humerus,  one  hand  should  grasp  the  head 
of  the  bone  while  the  other  rotates  the  shaft.  Naturally  if  there  is  a 
false  point  of  motion  the  shaft  and  head  of  the  bone  will  not  rotate 
together.  In  fractures  of  the  ribs  and  pelvic  bones,  the  fingers  should 
be  placed  upon  either  side  of  the  supposed  seat  of  fracture  and  alter- 
nately raised  and  depressed  to  determine  whether  a  false  point  of  motion 
exists  or  not. 

A  false  point  of  motion  is  the  most  positive  sign  of  a  fracture. 
Crepitation  should  not  be  relied  upon  too  much,  as  is  so  frequently  the 
case  with  the  beginner.  In  fractures  involving  the  joints  in  which  a 
false  point  of  motion  can  only  be  determined  with  difficulty,  if  at  all, 


580  THE   MECHANICAL   INJURIES 

crepitation  is  of  considerable  value.  When  elicited  in  fractures  of  the 
shaft,  it  is  a  valuable  diagnostic  sign.  It  also  indicates  that  the  frac- 
tured ends  are  not  overriding  or  separated  by  soft  tissues.  Crepitation 
elicited  by  pressure  over  the  seat  of  the  injury  may  be  due  to  the  dis- 
placement of  blood  clots,  but  crepitation  elicited  by  torsion  or  move- 
ments is  never  caused  in  this  way.  The  determination  of  a  false  point 
of  motion  and  the  elicitation  of  crepitus  are,  as  a  rule,  painful  to  the 
patient  and  injurious  to  the  soft  tissues.  They  should  be  omitted 
whenever  possible. 

Roenlgen-ray  Examination. — The  Roentgen-ray  examination  is  the 
most  important  aid  in  the  diagnosis  of  a  fracture.  It  is  essential  that 
one  should  have  an  accurate  knowledge  of  the  shadows  cast  by  nor- 
mal bones  taken  at  various  angles  in  order  that  normal  shadows  and 
the  lines  representing  epiphyseal  cartilages  will  not  be  interpreted  as 
fractures.  When  the  dressings  are  changed  a  fluoroscopic  examination 
should  be  made  to  determine  whether  or  not  the  fragments  are  in  appo- 
sition. If  a  deformity  still  persists,  attempts  at  correction  should  be 
made. 

In  all  cases  a  careful  examination  should  be  made  to  determine 
whether  large  blood  vessels,  nerves,  and  tendons  have  been  contused  and 
lacerated. 

Traumatic  and  Pathological  Fractures. — It  may  be  exceedingly  dif- 
ficult to  differentiate  between  a  traumatic  and  a  pathological  fracture 
if  the  disease  (tumor,  chronic  inflammation,  atrophy)  has  given  rise  to 
no  symptoms  before  the  fracture  occurred,  or  if  trauma  has  been  an 
accessory  factor.  If  the  trauma  was  not  severe  enough  to  have  frac- 
tured a  healthy  bone,  then  the  suspicion  of  abnormal  fragility  due  to 
some  pathological  process  should  arise.  If  the  Roentgen-ray  picture 
gives  no  assistance  in  making  the  diagnosis,  the  subsequent  clinical 
course  alone  can  decide  whether  the  fracture  is  pathological  or  not. 
Tumors  which  develop  at  the  seat  of  a  fracture  are  classified  as  "  cal- 
lus "  tumors.     They  are  usually  sarcomas. 

Clinical  Course. — A  swelling  varying  in  size  usually  develops  at  the 
seat  of  fracture  during  the  first  two  or  three  days.  Discoloration  of 
the  skin  which  rapidly  develops  is  due  to  the  infiltration  of  the  soft 
tissues  with  blood.  It  is  most  marked  in  fractures  associated  with  dis- 
placement and  comminution,  for  in  these  cases  the  soft  tissues  are 
contused  and  lacerated  by  the  fracturing  violence.  Fractures  involving 
the  joints  are  always  accompanied  by  an  extravasation  of  blood  into  the 
joint  cavity.  Frequently  tlie  swelling  is  aggravated  by  an  (I'dematous 
infiltration  of  the  tissues,  the  result  of  an  inflammatory  I'caction  which, 
as  a  rule,  continues  but  a  few  days.  Quite  frc(|uently  serous  and  sero- 
ha^morrhagic  ])lebs  develop  in  the  swollen,  tense,  and  discolored  skin. 


MECHANICAL    INJURIES   OF   THE    DIFFERENT   TISSUES  581 

During  the  first  week  a  slight  elevation  of  temperature  (so-callod  aseptic 
fever)  is  common.  This  fever  is  caused  by  the  absorption  of  blood  and 
tissue  fluids  from  the  tissues  about  the  seat  of  fracture.  Fat  may  be 
liberated  and  gain  access  to  and  circulate  in  the  blood  after  crushing 
injuries  of  the  bone  marrow.  If  present  in  large  amounts  it  may  cause 
fat  embolism,  the  symptoms  of  which  vary  depending  upon  the  viscus 
or  organ  chiefly  involved.  The  fat  is  excreted  in  the  urine,  and  if  there 
is  a  suspicion  of  fat  embolism,  which  usually  develops  in  from  fifty- 
four  to  seventy-two  hours,  the  urine  should  be  carefully  examined. 

If  the  part  is  not  immobilized  soon  after  the  fracture,  the  patient 
experiences  severe  pain,  which  is  aggravated  by  manipulation  and  at- 
tempts at  movement.  The  swelling  and  discomfort  are  usually  greatly 
relieved  by  the  application  of  a  well-fitting,  immobilizing  dressing. 

In  from  one  to  two  weeks  the  swelling  disappears  and  the  pain  sub- 
sides. Then  a  spindle-shaped  swelling  which  surrounds  the  fractured 
ends  can  be  felt.  This  swelling  enlarges  for  several  weeks,  but  grad- 
ually becomes  smaller  and  harder,  resulting  in  firm  union  of  the  frac- 
tured ends.  This  new  tissue  ^^•llich  develops  at  the  seat  of  fracture  is 
called  the  callus. 

Callus  Formation. — The  regenerative  changes  leading  to  callus  for- 
mation may  be  best  followed  in  animal  experiments.  The  first  change 
indicative  of  regeneration  consists  of  a  proliferation  of  the  cells  of  the 
periosteum  and  medulla.  Proliferative  changes  may  be  seen  within 
twenty-four  hours  after  the  fracture  of  a  bone.  A  vascular  granulation 
tissue  develops  from  the  periosteum,  which  frequently  is  lacerated  and 
separated  from  the  subjacent  bone  by  blood  clots.  At  the  end  of  the 
first  week  islands  of  osteoid  and  cartilaginous  tissue,  between  which 
lie  marrow  cells,  are  found  within  this  newly  formed  tissue.  Bone  is 
formed  from  the  external  or  periosteal  callus,  which  extends  some  dis- 
tance on  either  side  of  the  fracture,  as  the  result  of  the  deposition  of 
calcium  salts.  During  this  process  the  embryonal  granulation  tissue 
gradually  becomes  transformed  into  bone  of  an  adult  type.  When  the 
fractured  ends  are  not  properly  immobilized  and  are  subject  to  repeated 
displacements,  the  cartilage  persists  and  is  not  transformed  into  lioiie. 
The  internal  or  medullary  callus  forms  more  slowly  in  long  bones  than 
the  external  callus.  It  is  composed  of  osteoblasts,  which  first  produce 
osteoid  tissue  and  later  bone.  The  medullary  cavity  of  the  fractured 
ends  of  the  bone  are  at  first  closed  by  this  tissue. 

If  the  fractured  ends  are  held  in  apposition,  bone  formed  bj^  the 
periosteimi  and  bone  marrow  rapidly  unites  them.  If  the  ends  are 
widely  separated,  the  external  and  internal  callus  proliferate  to  fill  in 
the  gap  and  bridge  over  the  si)ace  between  them. 

The  fibrous  tissue  about  a  fracture  assists  in  the  formation  of  new 


582  THE   MECHANICAL    INJURIES 

bone  when  its  regenerative  activitj'  is  stiiiuilated  b.y  contusion  and  lacer- 
ation. The  proliferating  fibrous  tissue  forms  a  granulation  tissue  which 
sends  processes  out  into  the  intermuscular  septa  and  bridges  over  joints, 
causing  anchylosis.  These  changes  resemble  somewhat  those  observed  in 
the  traumatic  forms  of  myositis  ossificans.  After  fracture  of  adjacent 
bones  miion  of  the  two  masses  of  callus  may  lead  to  synostosis.  Synos- 
tosis of  the  radius  and  ulna  occasionally  occurs  after  fracture  of  these 
two  bones. 

Consolidation  of  the  Callus. — A  callus  gradually  enlarges  for  four 
or  five  weeks  and  then  undergoes  ossification,  which  is,  as  a  rule,  com- 
pleted in  the  following  four  weeks.  The  spongy  mass  of  callus  then 
becomes  condensed  and  transformed  into  a  less  massive  but  firmer  tissue, 
which  resembles  histologically  the  compact  substance  of  normal  bone. 
During  this  transformation  the  excessive  callus  is  absorbed,  the  jagged 
ends  of  the  bone  are  smoothed  off,  and  the  displaced  splinters  encapsu- 
lated or  digested.  The  medullary  canal  is  reestablished  when  the  frac- 
tured ends  are  in  fairly  good  apposition  in  the  same  axis,  but  it  remains 
closed  M'hen  the  ends  override  and  are  displaced  longitudinally.  After 
a  few  years  a  distinction  can  no  longer  be  made  between  old  and  new 
bone,  and  only  a  small  irregularity  can  be  noted  at  the  seat  of  the 
former  fracture. 

The  Amount  of  Callus  Formed. — The  amount  of  callus  formation  in 
different  fractures  varies  widely.  A  small  amount  of  callus  is  formed 
in  fractures  with  but  little  laceration  of  the  periosteum  and  in  fissures. 
An  excessive  amount  of  callus  is  formed  when  the  periosteum  is  badly 
injured,  when  the  bones  are  comminuted,  and  when  the  soft  tissues 
are  contused.  Necrotic  tissue  and  extravasated  blood  stimulate  the 
tissues  to  proliferation  and  favor  the  development  of  large  amounts  of 
callus.  Ordinarily  callus  formation  is  more  marked  in  fractures  of  the 
diaphysis  than  in  those  of  the  epiphysis,  but  even  in  the  latter,  espe- 
cially if  comminuted,  excessive  callus  formation  is  not  at  all  infrequent. 
In  fractures  of  the  short  and  flat  bones  but  little  callus  is  formed,  and 
it  develops  from  the  bone  marrow. 

Repair  of  Cartilage. — Fractures  of  the  chondral  and  laryngeal  carti- 
lages are  repaired  by  a  callus  which  develops  from  fibrous  tissues  and 
later  resembles  histologically  spongy  bone.  Fissures  of  the  articular 
cartilages  are  repaired  by  fibrous  tissue. 

Time  Bequirvd  for  Repair  of  a  Fraeture. — The  time  required  for 
the  repair  of  a  simple  fracture  is  usually  about  sixty  days.  Gurlt's 
statistics  show  that  two  weeks  are  refpiircd  for  the  repair  of  fractures 
of  the  phalanges,  three  weeks  for  those  of  the  metatarsal  bones  and 
ri])s,  four  weeks  for  those  of  the  clavicle,  five  .weeks  for  those  of  the 
bones  of  the  forearm,  six  weeks  for  those  of  the  humerus  and  fibula, 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  583 

seven  weeks  for  those  of  the  neek  of  the  hnnierns  and  tibia,  ei^rht  weeks 
for  those  of  both  bones  of  the  leg',  ten  weeks  for  those  of  the  shaft  of 
the  femnr,  twelve  weeks  for  those  of  the  neek  of  the  femur.  Consolida- 
tion occurs  rapidly  in  children,  and  is  complete  in  most  bones  in  from 
two  to  three  weeks.  Union  is  much  more  rapid  when  the  individual  is 
healthy  than  when  diseased. 

Delayed  and  Non-union. — The  causes  of  delayed  and  non-union  may 
be  local  or  general.  If  the  general  condition  of  the  patient  is  bad  as 
the  result  of  previous  sickness  union  may  be  delayed.  Cachexia  (fol- 
lowing and  a.ssociated  with  infectious  diseases  and  malignant  growths), 
senile  marasnuis,  atrophy  of  bone  associated  with  diseases  of  the  central 
nervous  system,  and  diseases  of  the  bone,  such  as  rickets  and  osteo- 
malacia, interfere  with  callus  formation.  Among  the  local  causes  inter- 
fering with  repair  may  be  mentioned  marked  displacement  and  over- 
riding of  fragments,  the  interposition  of  soft  tissues,  large  ha?matomas 
between  the  fractured  ends,  extensive  destruction  of  the  periosteum  and 
medullary  substance  with  comminution  of  the  bone,  poor  nutrition  of 
a  fragment  following  a  fracture  into  the  joint,  the  separation  of  an 
apophysis  or  the  thrombosis  of  the  nutrient  artery,  and  finally  sup- 
purative osteitis,  the  infection  occurring  at  the  time  of  the  fracture  or 
later  through  the  blood. 

Pseudartltrosis  and  Xeartlirosis. — As  a  result  of  one  of  the  above  con- 
ditions callus  formation  may  be  either  delayed  or  completely  interfered 
with.  If  union  is  delayed,  a  marked  enlargement  persists  for  some  time, 
but  finally  after  a  relatively  long  interval  the  callus  becomes  condensed 
and  firm  union  occurs.  Not  infrequently  when  union  is  delayed  the 
bone  is  refractured  by  attempts  at  movement,  but  the  convalescence  is 
not  markedly  prolonged,  as  the  repeated  insults  stimulate  the  germinal 
tissue  to  the  more  rapid  formation  of  solid  bone.  If  bony  union  fails 
a  false  point  of  motion  persists  and  a  pseudarthrosis  develops.  In  a 
pseudarthrosis  the  fractured  ends  are  either  separated  by  soft  tissues 
or  are  united  by  a  connective-tissue  bridge.  Move  rarely  a  true  joint 
forms  between  the  fragments,  the  ends  of  which  are  rounded  off  and 
covered  with  cartilage  and  enclosed  in  a  mass  of  connective  tissue  re- 
sembling the  capsule  of  a  joint.  Such  a  false  joint  contains  a  fluid 
resembling  synovia,  and  simulates  closely  a  joint  which  has  undergone 
the  pathological  changes  associated  with  arthritis  deformans.  The 
amount  of  interference  with  function  in  these  cases  depends  upon  the 
position  of  the  bone  involved.  A  pseudarthrosis  involving  a  rib  causes 
no  functional  disturbance,  while  a  pseudarthrosis  in  one  of  the  bones 
of  the  extremities  prevents  the  bearing  of  weight  upon  the  bone.  At 
times  the  extremity  may  be  used,  after  the  fragments  have  been  fixed 
by  muscular  contraction. 


584  THE  MECHANICAL  INJURIES 

The  bad  results  following  simple  fraetnrcs  are  usually  due  to  asso- 
ciated injuries  of  the  soft  tissues,  to  the  improper  reduction  and  immo- 
bilization of  the  fragments,  and  to  the  loss  of  function  following  long- 
continued  immobilization. 

Complicatwns. — Crushing  of  the  bone  marrow,  which  occurs  to  a 
greater  or  less  extent  in  every  fracture,  may  be  followed  by  the  absorp- 
tion of  fat  and  fat  embolism.  Injuries  of  arteries,  veins,  nervas,  mus- 
cles, and  tendons  may  be  caused  by  the  fracturing  violence,  or  by  the 
displacement  of  fragments  insufficiently  or  improperly  innnobilized. 
Extravasations  of  blood,  pulsating  hamiatomas,  traumatic  aneurysms, 
thrombosis,  gangrene  of  an  extremity,  paralysis,  and  muscular  con- 
tractures may  follow  such  injuries.  Intra-articular  fractures  are  accom- 
panied by  an  extravasation  of  blood  into  the  joint  which  frequently 
causes  a  synovitis  and  subsequent  fibrous  anchylosis.  In  intra-articular 
fractures  the  displaced  fragment  may  interfere  with  motion,  and  be- 
sides free  bodies  may  develop  or  changes  resembling  those  of  arthritis 
deformans  occur  after  contusion  and  laceration  of  the  tissues  forming 
the  joint.  In  some  cases  the  changes  following  the  extravasation  of 
blood  into  the  joint,  such  as  serous  synovitis  and  distention  of  the  cap- 
sule, are  very  pronounced. 

A  number  of  functional  disturbances  which  develop  depend  upon 
the  conditions  at  the  seat  of  the  fracture.  Besides  functional  disturb- 
ances caused  by  vicious  union,  pseudoarthrosis  and  synostosis,  are  those 
caused  by  the  pressure  of  fragments  of  bone  and  callus  upon  the  vessels 
and  nerves.  Thrombosis,  interference  with  circulation,  and  nervous  dis- 
turbances, which  may  even  end  in  paralysis  and  are  often  caused  by 
inclusion  of  nerves  in  the  callus  (the  musculospiral  nerve  being  fre- 
quently caught  in  the  callus  after  fractures  of  the  shaft  of  the  humerus), 
are  some  of  the  sequehe.  Necrosis  of  the  bone  following  infection  and 
suppuration  of  the  bone  rarely  occur  in  simple  fractures. 

Trophic  Disturhances. — Long-continued  disuse  following  immobiliza- 
tion of  the  injured  extremity  frequently  leads  to  trophic  disturbances. 
The  beginning  of  trophic  disturbances  Mdiich  usually  develop  after  some 
weeks  is  indicated  by  a  diminution  in  the  size  of  the  part.  The  skin 
becomes  soft,  thin,  and  smooth,  the  nniscles  atrophy  as  a  result  of  dis- 
ease and  trophic  changes  in  the  spinal  centers  which  follow  peripheral 
irritation  associated  with  the  trauma  or  accompanying  inflammation 
( Paget- Vulpian  reflex  atrophy).  In  these  cases  a  Roentgen-ray  picture 
taken  after  six  or  eight  weeks  reveals  a  marked  atrophy  of  the  bone 
and  changes  in  its  internal  structure  (Sudeck).  The  muscles  and  fascia 
atrophy,  the  tendons  no  longer  glide  freely  in  their  sheaths,  the  func- 
tion of  the  joints  is  interfered  with,  even  when  not  injured,  as  the 
result  of  adhesions  and  degeneration  of  the  articular  cartilages.     The 


MECHANICAL   INJURIES  OF   THE   DIFFERENT  TISSUES  585 

joint  changes  associated  with  ininio])ilization  are  most  marked  in  adults 
and  old  people.  If  a  stiff  joint  is  used  or  manipulated  too  I'oughly  at 
tirst,  an  acute  serous  or  serohjeuKn-rhagic  exudate  may  form  as  the  result 
of  laceration  of  the  vessels  in  the  contracted  capsule.  In  children  the 
growth  of  the  entire  extremity  may  be  interfered  with  if  a  pseud- 
arthrosis  develops  or  the  function  of  the  part  is  interfered  with  as  the 
result  of  anchylosis  of  one  of  the  joints. 

(Edema  Following  Fractures. — Circulatory  disturbances  are  most 
connnon  after  fractures  of  the  bones  of  the  lower  extremity.  They 
appear  after  the  first  attempts  are  made  to  use  the  parts.  Passive  con- 
gestion and  (edema  are  due  to  weakness  of  the  nuiscles,  which  interferes 
with  the  venous  circulation,  and  to  venous  thrombosis. 

Decubitus  and  Hypostatic  Pneumonia. — Old  people  are  prone  to 
develop  bedsores  and  hypostatic  pneumonia  when  c(mfined  to  bed  for 
any  length  of  time. 

Thrombosis  and  Embolism. — Pulmonary  and  cardiac  embolism, 
which  are  usually  fatal,  may  follow  thrombosis  of  the  veins  about  the 
fracture.  A  persistent  and  troublesome  oedema,  frequently  associated 
with  nutritional  disturbances,  is  due  to  venous  thrombosis.  Thrombosis 
may  be  due  to  a  weak  action  of  the  heart,  to  rupture  and  laceration  of 
the  deep  veins,  and  to  pressure  exerted  by  the  fractured  ends  of  the  bone 
or  by  the  callus.  These  complications  occur  most  frequently  after  frac- 
tures of  the  bones  of  the  leg  and  in  old  people. 

Persistent  pain  at  the  seat  of  fracture  is  another  sequela  which  often 
interferes  with  the  usefulness  of  the  extremity.  It  is  always  present 
when  the  callus  is  recent,  but  usually  disappears  as  it  becomes  older 
and  more  solid.  In  old  people,  however,  it  may  persist  or  return  after 
excessive  use  of  the  part  or  with  every  change  of  weather. 

Prognosis. — The  prognosis  of  fractures  of  the  different  bones  dif- 
fers widely.  Fissures,  green-stick  fractures,  and  fractures  with  but 
slight  displacement  offer  the  best  prognosis.  The  prognosis  of  com- 
minuted fractures,  of  fractures  with  marked  displacement,  and  of  those 
associated  with  injuries  of  the  soft  parts  and  neighboring  joints  is  bad, 
as  shortening,  pseudarthrosis,  and  stiffness  may  follow  and  persist. 
Fractures  in  j^oung  people  heal  m,uch  more  readily  than  those  in  old 
people,  and  the  prognosis  is  much  better  in  healthy  people  than  in  those 
debilitated  by  chronic  infections  or  constitutional  diseases. 

Statistics  showing  the  results  folloM'ing  different  fractures  are  given 
by  Haenel,  Jottkowitz,  Loew,  Bliesener,  Wolkowitch,  and  others. 

Treatment. — The  success  of  the  treatment  depends  largely  upon  the 
way  in  which  the  first  dressing  is  applied.  In  all  fractures  which  occur 
outside  of  the  patient's  home,  an  emergency  dressing  should  be  applied 

which  should   immobilize   the   fragments   during  transportation   to   the 

38 


586  THE   MECHANICAL   INJURIES 

home  or  hospital,  preventing  the  displacement  of  the  fractured  ends,  so 
that  they  cannot  injure  the  soft  tissues,  penetrate  the  skin,  or  cause 
excessive  pain.  A  broken  arm  may  be  immobilized  against  the  chest  by 
a  bandage  or  sling  and  supported  by  the  uninjured  arm.  Temporary 
immobilization  of  fractures  of  the  lower  extremity  is  far  more  difficult. 
Wooden  splints,  broom  handles,  branches  of  trees,  boards,  and  in  war 
sabers  and  guns  and  other  weapons,  have  been  used  to  immobilize  the 
parts  during  transportation  of  the  wounded.  These  improvised  splints 
are  placed  upon  either  side  of  the  fractured  part  over  the  clothing, 
and  extend  far  enough  to  immobilize  the  joints  above  and  below  the 
seat  of  fracture.  In  fractures  of  the  femur  the  temporary  immobilizing 
dressing  should  extend  from  the  external  aspect  of  the  foot  to  the  costal 
margin,  and  should  be  held  in  place  by  handkerchiefs,  straps,  cords,  or 
suspenders.  If  there  is  nothing  at  hand  which  can  be  used  to  immo- 
bilize the  part,  the  injured  leg  may  be  bound  to  the  uninjured  one. 
[A  most  useful  dressing  is  the  blanket  splint,  made  by  folding  a  blanket 
lengthwise  once  and  rolling  each  end  up  into  a  firm  roll  over  a  lath 
or  piece  of  wood.  The  fractured  part  is  then  placed  between  the  rolls, 
Mdiich  are  held  in  place  by  thi-ee  or  four  pieces  of  a  roller  bandage.] 

If  the  individual  is  injured  at  home,  he  should  be  placed  in  bed  and 
the  fractured  pai't  should  be  inmiobilized  between  long  sandbags.  Fre- 
quently a  physician  is  called  to  adjust  a  temporary  dressing  which  will 
permit  of  easy  and  safe  transi)ortation  of  the  patient  to  a  hospital.  In 
doing  this  the  part  should  be  handled  gently  and  the  following  pro- 
cedure should  be  followed :  The  parts  above  and  below  the  seat  of  frac- 
ture should  be  held  firmly,  and  the  limb  should  then  be  gradually  ele- 
vated, gentle  traction  being  maintained  upon  the  lower  fragment.  The 
clothing  should  then  be  removed.  If  there  is  any  difficulty  in  doing 
this  the  clothes  may  be  opened  along  the  seam  or  cut  off.  The  fracture 
should  then  be  reduced  as  well  as  possible  without  anjpsthesia,  and  after 
covering  the  bony  prominence  with  cotton  a  wooden  or  a  molded  plaster- 
of-Paris  splint  should  be  applied. 

The  object  of  the  treatment  of  a  fracture  is  to  secure  firm  union, 
in  good  i)()sition,  of  the  fi'actured  ends,  and  complete  return  of  func- 
tion as  early  as  is  compatible  with  the  character*  of  the  fracture.  Spe- 
cial works  on  fractures  by  Scudder,  IToffa,  Ilelferieh,  and  Stimson  in- 
dicate the  line  of  treatment  which  should  be  followed  to  secure  good 
cosmetic  and  functional  results  in  the  different  types  of  fractures. 

Reduction  of  a  Fracture. — The  first  indication  in  the  treatment  of 
a  simple  fracture  is  to  bring  the  fractured  ends  in  good  apposition, 
thus  correcting  the  deformity.  This  is  called  reduction  or  setting  of 
a  fracture. 

AVhcn  the  displacement  is  great  and  severe  pain  is  experienced  when 


MECHANICAL   INJURIES  OF   THE   DIFFERENT  TISSUES  587 

the  part  is  manipulated,  the  fracture  should  be  reduced  uiidir  gas 
anassthesia.  The  skin  about  the  part  should  be  shaved  and  stei'ilized 
in  order  that  the  infection  of  ha?raatomas  and  of  the  small  cutaneous  or 
serous  blebs  may  be  prevented. 

Fractures  of  the  bones  of  the  trunk  and  face  can  usually  be  reduced 
by  pressure.  ]\Iany  fractures  into  the  joints  may  be  reduced  by  chang- 
ing the  position  of  the  joint  involved.  Reduction  of  fractures  of  the 
bones  of  the  arm  or  leg  should  be  performed  as  follows :  The  part 
proximal  to  the  fracture  should  be  grasped  and  held  firmly  by  an 
assistant,  and  the  surgeon  should  then  grasp  gently  the  distal  frag- 
ment and  exert  traction.  By  traction,  torsion,  bending,  or  lateral  mo- 
tion combined  with  coimterpressure,  the  deformity  is  reduced.  If  the 
proximal  fragment  is  so  short  that  it  cannot  be  controlled,  the  distal 
fragment  should  be  dressed  in  line  with  it.  [A  good  example  of  this 
principle  is  aftorded  by  fractures  of  the  femur  just  below  the  lesser 
trochanter.  The  upper  fragment  is  flexed,  abducted,  and  rotated 
slightly  outward  by  the  action  of  the  muscles  attached  to  it.  It  is  im- 
possible to  reduce  and  maintain  this  short  fragment  in  position,  so  the 
long  fragment,  which  can  be  controlled,  is  dressed  in  line  with  it.  The 
fragment  which  can  be  controlled  should  always  be  dressed  in  line  with 
the  fragment  which  cannot  be  controlled.]  At  least  one  quarter  of  the 
fractured  ends  should  be  in  apposition  after  reduction.  The  results  of 
attempts  at  reduction  can  best  be  determined  by  Roentgen-ray  exami- 
nations. 

In  fractures  of  the  olecranon  the  forearm  should  be  dressed  in  exten- 
sion. In  fractures  of  the  upper  third  of  the  fenuir  the  lower  frag- 
ment should  be  flexed,  abducted,  and  rotated  outward.  Fractures  about 
joints  should  always  be  dressed  in  the  position  of  overcorrection ;  for 
example,  in  Colles's  fracture  the  hand  should  be  dressed  in  flexion,  in 
Pott's  fractui-e  the  foot  should  be  rather  strongly  inverted. 

Immobilization. — The  fragments,  when  reduced,  should  be  held  in 
place  by  appropriate  dressings.  It  is,  as  a  rule,  more  difficult  to  main- 
tain the  fragments  in  good  position  than  it  is  to  reduce  them. 

Pluster-of-Paris  Dressing. — If  the  injury  is  recent  and  there  is  no 
marked  swelling  of  the  soft  parts,  it  is  best  to  emi)loy  a  pla.ster-of-Paris 
dressing,  during  the  application  of  which  the  fragments  should  be  main- 
tained in  correct  position  by  traction  and  counterpressure.  If  there  is 
considerable  swelling,  the  extremity  may  be  immobilized  in  a  box  or 
papier-mache  splint  until  the  swelling  has  subsided,  and  then  a  plaster- 
of-Paris  dressing  should  be  applied.  The  plaster-of-Paris  bandage  is 
empk\yed  in  two  ways:  As  a  circular  dressing,  encasing  the  part 
(Matthysen,  1852),  and  as  a  molded  splint  (Beely,  1878).  The  band- 
age, as  usually  employed,  consists  of  crinolin  or  cheese  cloth,  which  is 


588 


THE   MECHANICAL   INJURIES 


infiltrated  with  powdered  plaster  of  Paris.  The  bandage  is  applied 
after  the  extremity  has  been  covered  with  a  flannel  bandage  or  cotton, 
which  is  held  in  position  by  a  light  mull  or  flannel  bandage.  Bony 
prominences  and  projecting  tendons  should  be  carefully  protected.  The 
bandage  may  be  reinforced  by  pieces  of  wood,  aluminum  plates,  or  strips 
of  tin. 

Many  considered  the  molded  plaster-of-Paris  dressing  safer  than  the 
circular.  In  applying  such  a  dressing  to  the  leg,  strips  of  flannel  are 
cut  of  the  desired  length  and  width,  and  then  a  number  of  layers  of 
a  plaster  bandage,  enough  to  afford  sufficient  strength,  are  laid  upon 
these.  The  dressing  is  then  molded  to  the  part  and  held  in  position 
by  a  roller  bandage.  This  dressing  can  be  easily  removed  when  it  is 
desired  to  massage  the  limb,  and  there  is  less  danger  of  ischaemic  con- 
tractures, gangrene,  etc.,  when  it  is  employed. 


Fig.  226. — Beely's  Molded  Plaster-of-Paris  Dressing  for  Fractures  of  the  Leg. 
The  dressing  is  provided  with  rings  to  be  used  for  suspension. 

Bad  Results  Folloiving  Poorly  Applied  Splints  and  Casts. — Any  im- 
mobilizing dressing  may  be  followed  by  bad  results  if  applied  too  tightly 
or  if  the  turns  composing  it  are  applied  unevenly.  When  a  cast  is 
applied  to  an  extremity,  the  fingers  or  toes,  as  the  case  may  be,  should 
not  be  included.  They  should  be  inspected  frequently,  their  color  and 
freedom  of  motion  noted.  The  dressing  should  be  split  open  or  re- 
moved at  once  if  the  parts  become  congested  or  anaemic  or  paralyzed. 
The  most  serious  consequences,  such  as  gangrene  of  the  extremity, 
thrombosis  of  the  principal  vessels,  and  ischa-mic  contractures,  may 
follow  the  pressures  of  a  poorly  applied  plaster-of-Paris  dressing. 
Ulcers  caused  by  pi'essure  of  a  tight  cast  are  a  source  of  danger,  as 
they  provide  infection  ati'ia  for  ])yogeiiic  bactoi'ia.  All  l)oiiy  promi- 
nences, sharp  fragments,  and  |)i'()iiiiiiciil  tendons  slionid  be  paddiMl  in 
order  to  prevtmt  pressui'e  iieci-osis. 

The  first  plaster-of-Paris  dressing  should  be  changed  at  the  end  of 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  589 

the  first  week,  or,  at  the  hitest,  after  tlie  second  week.  The  first  dressing 
I)('c(>nu's  loose  when  the  sweilinjU'  suV)si(h's,  and,  besides,  the  position  of  the 
fragments  can  often  be  improved  and  massage  given  when  llie  dressing 
is  changed.  When  the  dressing  is  changed  the  skin  should  be  washed 
otf,  and  if  there  is  an  eczema  it  should  be  dressed  with  a  dusting  powder 
or  an  ointment.  The  inunobilized  joints  and  the  musch's  should  be 
massaged  before  another  dressing  is  a])piied,  unless  there  is  some  contra- 
indication. 

Application  of  the  Second  Cast. — The  amount  of  padding  in  the 
second  cast  may  be  greatly  reduced  as  a  rule.  [Some  advise  applying 
the  plaster-of-Paris  dressing  directly  to  the  skin  after  it  has  been  oiled 
or  covered  with  vaseline.  If  a  light  flannel  bandage  is  applied  before 
the  plaster  dressing  is  put  on,  the  patient  will  be  more  comfortable,  and 
at  the  same  time  the  parts  will  be  better  protected.  There  are  no  advan- 
tages in  applying  the  cast  directly  upon  oiled  or  vaselined  skin.] 

Amhidatonj  Dressing. — Convalescence  is  hastened  if  the  muscles 
receive  massage,  atrophy  being  prevented  in  this  way,  and  if  the  joints 
adjacent  to  the  fracture  are  massaged  and  moved  early.  An  ambulatory 
splint  is  employed  in  the  treatment  of  fractures  of  the  lower  extremity 
by  many  surgeons.  The  best  ambulatory  splints  are  ITessing's  molded 
iron  splint,  Thomas's  hip  splint,  the  molded  iron  splint  of  von  Bruns, 
and  the  circular  plaster  casts  advised  by  Krause,  Bardeleben,  K(n-sch, 
Albers,  and  others.  AVhen  applied  they  are  carefully  molded  to  fit  over 
bony  prominences,  such  as  the  tibia,  the  condyles  of  the  femur,  the  tro- 
chanter, and  the  pelvic  bones  in  fractures  of  the  fennir.  These  dress- 
ings permit  the  patient  to  leave  the  bed  before  callus  formation  is 
complete,  which  is  of  the  greatest  importance  in  treating  fractures  in 
old  people. 

Extension  Dressings. — The  extension  dressing  devised  by  Buck  is 
preferable  in  many  cases  to  the  iron  splints  and  plaster-of-Paris  dress- 
ing. This  dressing  is  especially  valuable  in  reducing  and  maintaining 
in  correct  position  certain  fractures  characterized  by  marked  displace- 
ment. In  applying  this  dressing,  broad  strips  of  adhesive  plaster  are 
applied  on  either  side  of  the  limb  and  carried  a  little  above  the  seat 
of  fracture.  These  strips  of  adhesive  plaster  are  attached  to  a  foot-  or 
hand-board,  as  the  case  may  be,  to  which  is  attached  a  coi-d  which  runs 
over  a  pulley  and  is  secured  to  a  weight.  The  adhesive  plaster  is  bound 
to  the  leg  or  arm  by  turns  of  a  roller  bandage.  The  cord  usually  sup- 
ports a  weight  of  from  eight  to  ten  pounds,  and  continuous  longitudinal 
traction  is  made  in  this  way.  This  dressing  is  effective  in  any  position 
of  the  part.  If  the  foot  of  the  bed  is  elevated,  the  weight  of  the  body 
usually  affords  sufficient  counterextension.  The  extension  dressing  is 
fre(|uently  combined  with  Volkmann's  sliding  splint    (Fig.  2"27).     This 


590 


THE   MECHANICAL   INJURIES 


extension  dressing  has  a  number  of  advantages:  (1)  The  displacement 
is  gradually  overcome  without  much  pain,  and  the  fragments  are  held 
in  good  position;  (2)  the  part  may  be  easily  inspected  and  the  position 
of  the  fragments  improved,  if  necessary,  by  pressure  and  counterpres- 
sure;  (3)  the  joints  may  be  moved  after  a  few  days,  and  the  stiffness 


Fig.  227. — Buck's  Extension  Combined  with  Volkmann's 
Sliding  Splint  in  the  Treatment  of  a  Fracture 
through  the  Middle  Third  of  the  Femur.  Counter 
traction  by  a  perineal  band;  also  lateral  traction  upon 
upper  fragment  to  correct  outward  displacement. 


and  synovitis  associated  with  long-continued  immobilization  may  be  pre- 
vented (Bardenheuer).  Repair  of  the  fracture  is  not  delayed,  but 
rather  hastened  by  the  limited  amount  of  motion  permitted  by  such  a 
dressing.  Buck's  extension  has  been  generally  adopted  by  the  profes- 
sion in  the  treatment  of  fractures  of  the  shaft  and  neck  of  the  femur. 
The  same  principle  is  being  used  more  and  more  in  the  treatment  of 
other  fractures,  especially  those  involving  joints. 

Bardenheuer  has  devised  an  adjustable  apparatus  for  the  treatment 
of  fractures  of  the  upper  extremity,  in  which  extension  is  secured  by  a 
spring,  instead  of  by  a  weight  and  pulley. 

Massage  and  early  passive  motion  are  imjiortant  factors  in  securing 
a  return  of  function,  'j'lic  fiindion  of  the  part  may  be  impaired:  (1) 
By  stiffness  of  the  joints  and  adhesions  of  the  tendons  to  their  sheaths; 
(2)  by  muscular  ati-ophy;  (8)  by  malposition  of  the  fragments  of  the 
bone  or  bones. 

Early  Massage  aud  Passive  Motion  in  the  Treatment  of  Fractures. — 
Stiffness  of  the  joints  and  adhesions  between  the  tendons  and  their 
sheaths  may  be  the  cause  of  severe  functional,  distui'bances.  Lucas 
Championniere  demonstrated  some  twenty-five  years  ago  that  in  a  num- 


MECHANICAL   INJURIES   OF  THE   DIFFERENT  TISSUES 


5Ui 


ber  of  fractures  the  fragments  have  no  tendency  to  become  displaced 
when  they  are  once  properly  reduced,  and  that  most  excellent  functional 
results  could  be  obtained  without  any  prolongation  of  the  period  of  re- 
pair by  early  massage  of  the  joints  and  tendons  adjacent  to  the  frac- 
ture. He  also  found  that  even  in  fractures  with  a  tendency  to  marked 
displacement,  the  wearing  of  an  innnobilizing  dressing  for  two  weeks 
was  sufficient.  He  has  done  a  great  service  in  emphasizing  the  so-called 
functional  treatment  of  fractures,  but  has  carried  it  too  far. 

The  advantage  to  be  derived  from  early  motion  and  massage  cannot 
be  denied.  An  effort  should,  however,  be  made  to  maintain  the  frag- 
ments in  good  apposition,  even  if  clinical  experience  has  demonstrated 
that  the  functional  results  following  union  in  poor  position,  but  asso- 
ciated with  free  motion  of  the  joints  and  the  absence  of  muscular 
atrophy,  are  better  than  those  following  union  of  the  fragments  in  per- 
fect position,  but  associated  with  stiffness  of  the  joints  and  atrophy  of 
the  muscles.  Jordan  and  others  pursue  the  proper  course  when  they 
combine  immobilization  and  the  Championniere  treatment.  Bardenheuer 
lays  great  stress  upon  the  treatment  of  fractures  by  extension  combined 
with  early  motion  and  massage. 

The  fragments  should  be  maintained  in  good  apposition  by  immo- 
bilization or  extension  until  union  is  firm  enough  to  give  fairly  good 
support,  but  not  as  formerly,  until  the 
callus  has  undergone  complete  consol- 
idation. In  many  fractures  immobil- 
ization for  two  or  three  weeks  is  suf- 
ficient, but  occasionally  a  much  longer 
time  is  required.  If  the  period  of 
immobilization  exceeds  two  weeks,  mas- 
sage should  be  employed,  especially 
if  the  fracture  involves  a  joint.  An 
exception  to  this  rule  should  be  made 
in  the  treatment  of  fractures  occurring 
in  children.  Early  massage  of  a  frac- 
ture in  the  young  often  leads  to  exces- 
sive callus  formation,  while  even  long- 
continued  immobilization  in  a  cast 
which  may  be  required  in  difficult 
eases  does  not  cause  the  slightest  im- 
pairment of  function. 

I   do  not  believe  that  massage  of 
a   recent    fracture    is    indicated.      Im- 
mobilization continued  for  one  week  prevents  pain  and  causes  no  im 
pairment  of  function,  even  when  the  fracture  involves  a  joint.     Immo 


Fig.  228. — Supracondylar  Fracture 
OF  THE  Humerus,  Usual  Type. 
(von  Bergmann's  "Handbook  of 
Practical  Surgery.") 


592  THE  MECHANICAL   INJURIES 

bilizatioii  protects  against  a  iiiuHl)ei'  of  complications,  such  as  secondary 
haemorrhage  caused  hy  disphicement  of  the  fragments  and  laceration 
of  the  soft  tissues.  The  pain  and  swelling  rapidly  subside  when  an 
immobilizing  dressing  is  properly  applied. 

Massage,  when  first  applied,  should  consist  of  gentle  rubbing  of 
the  seat  of  fracture,  the  part  being  rubbed  from  the  periphery  toward 
the  trunk  for  fifteen  or  thirty  minutes.  If  there  are  abrasions  or 
large  wounds  of  the  skin,  massage  should  not  be  begun  until  these  are 
healed. 

Osteoclasis  and  Eeduction  hy  the  Open  Method. — If  union  of  the 
fragments  has  occurred  in  malposition  it  may  be  necessary  to  resort 
to  osteoclasis.  In  cases  in  which  it  is  impossible  to  reduce  the  fragments 
by  manipulation  and  to  maintain  them  in  good  apposition,  it  may  be 
necessary  to  resort  to  reduction  by  the  open  method. 

(rt)  Osteoclasis — artificial  fracture  of  the  callus — is  resorted  to  in 
those  cases  in  which  union  has  occurred  in  malposition,  as  a  result  of 
neglect  or  imperfect  immobilization,  or  because  of  the  inherent  dif- 
ficulties of  the  case.  If  the  callus  is  not  consolidated  it  may  be  easily 
fractured  by  manual  force  and  the  fragments  then  placed  in  proper 
position.  If  consolidation  has  become  complete,  it  may  be  necessary  to 
use  some  form  of  an  osteoclast.  The  osteoclast  holds  firndy  the  part 
of  the  bone  above  the  fracture,  and  by  slowly  bending  the  distal  seg- 
ment the  fracture  can  be  produced  at  any  desired  point.  In  some 
apparatus  (the  Schneider-Mennel)  the  force  is  obtained  by  means  of  a 
pulley,  traction  being  exerted  upon  the  fragment  to  be  broken. 

(&)  The  open  method  of  reduction  has  been  employed  for  some  time 
in  the  treatment  of  pseudarthrosis  and  in  old  cases  which  have  healed 
in  malposition.  In  this  method  the  fracture  is  exposed,  the  connective 
tissue  about  the  fracture  removed,  the  bone  is  cut  through  by  a  chisel, 
and  the  fractured  ends  are  given  some  definite  form,  so  that  they  will 
fit  together  fairly  well.  The  fragments  are  then  maintained  in  appo- 
sition by  sutures,  ivory  pegs,  or  nails.  Frequently  it  is  of  advantage  to 
chisel  indentations  or  serrations  in  the  fragments,  so  that  they  will  fit 
together  accurately. 

The  open  method  is  frequently  employed  in  the  treatment  of  frac- 
tures when  the  fragments  are  widely  separated  by  niuscular  action — for 
example,  in  the  treatment  of  fractures  of  the  olecranon,  patella,  and  os 
calcis.  A  number  of  surgeons  (Pfeil-Sehneider,  Lane,  Tuffier,  Fritz 
Konig,  Martin,  and  others)  employ  the  open  method  in  the  treatment 
of  fractures  in  wdiich  the  simple,  closed  method  is  employed  by  other 
surgeons. 

Fritz  Konig  especially  is  a  champion  of  the  open  method  in  the 
treatment  of  the  various  types  of  fractures.    He  considers  it  necessary 


MECHANICAL    IN  J  LOUIES   OF   THE    DIFFERENT  TISSUES  593 

or  at  least  of  advantage  in  the  treatment  of  fractures  of  the  shafts  of 
the  femur  and  humerus  with  marked  displacement  or  an  interposition 
of  soft  tissues,  of  simple  fractures  of  the  shaft  or  ulna  to  avoid  synos- 
tosis, of  multiple  fractures  of  the  lower  extremity,  for  the  separation 
of  fragments  of  bone  caused  by  muscular  action,  for  fractures  involving 
joints  with  a  rotation  or  dislocation  of  the  fragment  into  the  joint, 
for  fractures  associated  with  a  dislocation,  and  for  intracapsular  frac- 
tures of  the  neck  of  the  femur. 

The  most  favorable  time  to  attempt  reduction  by  the  open  method 
is  at  the  beginning  of  the  second  week  (Fritz  Konig).  At  this  time 
the  blood  has  been  absorbed,  the  injured  tissues  are  in  a  state  of  active 
regeneration,  and  the  blood  clot  and  the  fragments  of  tissue  which 
stinudate  callus  formation  have  become  united  with  the  surrounding 
parts.  If  an  operation  is  performed  early  and  the  loosened  tissues  and 
the  blood  clots  are  removed,  the  bone  is  deprived  of  the  natural  stimu- 
lus supplied  by  them.  A  deficient  callus  which  predisposes  to  pseudar- 
throsis  is  then  apt  to  form. 

{(■)  Technic  of  Reduction  hij  the  Open  Method,  Bone  Suture,  etc. — 
The  fragments  should  be  exposed  under  artificial  ischemia  obtained  by 
an  Esmarch  constrictor  or  a  jMartin  bandage.  After  the  ends  of  the 
fragments  have  been  freed  of  fibrous  tissue  and  approximated,  they 
should  be  united  by  suture,  wire  nails,  screws,  ivory  or  bone  pegs.  In 
applying  sutures  the  bones  are  first  drilled  and  catgut,  aluminum- 
bronze,  or  silver  wire  is  passed  through  the  drill  holes  and  tied  or 
twisted  after  the  fragments  are  placed  in  apposition.  Nickel-plated 
or  silver-plated  pins,  bone  or  ivory  pegs,  silver-plated  screws,  and 
the  bone  plates  introduced  by  IMr.  Lane  may  also  be  used.  If  the 
wound  can  be  closed,  primary  union  usually  occurs  when  the  neces- 
sary aseptic  precautions  have  been  taken.  Frequently  deformities  are 
not  prevented,  even  when  fractures  of  the  diaphysis  are  reduced  and 
fixed  in  the  ordinary  way  by  the  open  method.  In  these  cases  it  is  often 
advisable  to  use  an  intramedullary  splint,  a  piece  of  bone  or  ivory 
jx'g  l)eing  placed  in  the  medullary  canal  and  the  fragments  being  ap- 
proximated over  it.  [^lurphy  and  Neff  have  obtained  very  good  results 
in  a  number  of  cases  by  sawing  off  ol)li(iuely  the  ends  of  one  of  the 
fragments  and  then  forcing  this  end  into  the  medullary  cavity  of  the 
other  fragment.  The  results  are  the  same  as  those  obtained  l)y  use  of 
a  medullary  splint,  with  this  advantage  that  there  is  no  foreign  body 
to  interfere  with  the  process  of  repair.]  When  the  medullaiy  splint  is 
used,  a  wire  which  includes  the  splint  should  be  passed  through  the 
bone. 

After  closure  of  the  wound  an  immobilizing  dressing  is  ap])lied  as  in 
simple  reduction,  and  massage  and  passive  motion  are  begun  early. 


594  THE  MECHANICAL   INJURIES 

Treatment  of  Delayed  Union  and  Pseudarthrosis. — The  treatment  of 
delayed  callus  formation  has  alread.y  been  discussed  in  the  paragraph 
devoted  to  the  bloodless  treatment  of  pseudarthrosis. 

Injections  of  alcohol,  oil  of  turpentine,  tincture  of  iodin,  zinc  chlorid, 
lactic  acid,  or  blood  freshly  withdrawn  from  a  vein  are  employed.  Hot 
baths,  massage,  and  rubbing  together  of  the  fragments  may  be  used  to 
stinuilate  and  increase  regeneration  and  callus  formation.  Passive 
hypertemia  obtained  by  applying  daily  an  elastic  constrictor  proximal 
to  the  point  of  fracture  for  a  period  of  from  one  to  three  hours  may 
hasten  repair. 

Ambulatory  splints  may  be  of  advantage  in  treating  delayed  union 
of  the  lower  extremity,  for  the  irritation  to  which  the  fragments  are 
exposed  when  the  patient  is  walking  about  hastens  the  development  of 
bone.  In  many  cases  firm  union  which  has  been  delayed  for  many 
months  occurs  after  this  treatment.  It  is  a  mistake  to  apply  immo- 
bilizing dressings  which  cannot  be  easily  removed  and  prevent  early 
massage  and  passive  motion. 

Union  following  reduction  by  the  open  method  is  more  rapid  and 
complete  when  the  freshened  ends  can  be  brought  together  directly. 
If  a  space  remains  between  the  fragments  after  dissecting  out  a  near- 
throsis or  the  fibrous  tissue  between  them,  there  are  a  number  of  plastic 
procedures  which  may  be  resorted  to.  The  defect  may  be  overcome 
by  transplanting  bone  taken  from  a  neighboring  bone;  by  resection  of 
the  neighboring  bone,  causing  shortening  of  the  part;  by  transplanting 
a  section  of  dead  bone  which  has  been  sterilized  for  some  hours.  The 
transplanted  bone  is  attached  to  the  fractured  ends  by  sutures  or  is 
wedged  into  the  medullary  canal.  In  some  cases  it  is  advisable  to  take 
flaps  of  periosteum  and  bone  from  the  fractured  ends  to  bridge  over  the 
defect  (AV.  Mueller,  von  Eiselsberg).  In  large  defects  of  the  tibia  the 
method  advised  by  Ilahn,  in  which  the  lower  fragment  of  the  fibula  is 
sawn  through  and  then  inserted  into  the  medullary  cavity  of  the  tibia, 
may  be  used  to  advantage. 

If,  on  account  of  the  age,  the  general  condition,  or  lowered  resistance 
of  the  patient,  a  pseudarthrosis  cannot  be  treated  by  the  open  method, 
a  molded  splint  of  tlie  type  suggested  by  ITessing  should  be  employed. 
Tliis  splint  is  especially  valuable  in  treating  pseudarthrosis  of  the  lower 
extremity. 

(b)   OPEN   INJURIES  OF   BONES  AND   CARTILAGE 

Different  foi-ms  of  wounds  occui-  in  bones  and  cai'tilage.  Injuries 
of  the  ])eri(>s1("um  and  pericliondrium  are  ol"  less  constMiucnce  than  are 
injuries  of  Ixjtic  and  cartihige.  Simple  wounds  of  the  cartilages  of  the 
nose,  ears,  laiynx,  and  ribs  are  of  no  special  significance,  but  open  in- 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  595 

juries  (compound  fractures)  are  always  serious  because  of  the  dangers 
of  infection,  and  associated  injuries  of  important  structures.  Com- 
])()und  fractures  associated  with  small,  rapidly  healing  wounds  may  pur- 
sue much  the  same  clinical  course  as  simple  fractures.  Fractures  asso- 
ciated with  extensive  laceration  of  the  soft  parts  or  almost  complete 
separation  of  the  extremity  may  be  of  secondary  importance  when  com- 
pared to  the  gravity  of  the  complications. 

Relative  Frequency  of  Compound  Fractures. — The  statistics  of  Gurlt, 
Weber,  IMoi'itz,  and  Billroth  show  that  from  16  to  27  per  cent  of  all  frac- 
tures are  compound.  The  following  figures  indicate  the  relative  fre- 
quency of  compound  fractures  in  the  different  bones :  72  per  cent  of 
88  fractures  of  the  phalanges  of  the  fingers  and  toes,  44  per  cent  of 
52  fractures  of  the  metacarpal  and  metatarsal  bones  were  compound, 
while  17.9  per  cent  of  the  fractures  of  the  leg,  11.6  per  cent  of  those 
of  the  forearm,  7  per  cent  of  those  of  the  thigh,  and  6  per  cent  of  those 
of  the  humerus  were  compound  (von  Bruns). 

A  compound  fracture  may  be  produced  by  either  direct  or  indirect 
violence,  the  object  penetrating  tlie  soft  tissues  and  fracturing  the  bone, 
or  the  fragments  of  the  bone  being  forced  through  the  soft  tissue  by  the 
fracturing  violence.  A  compound  fracture  by  indirect  violence  may  be 
caused  by  a  displacement  of  the  fragments  at  the  time  of  the  fracture, 
or  from  necrosis  following  pressure  due  to  imperfect  reduction  of  the 
deformity  or  careless  treatment. 

Decubitus  developing  over  a  sharp  edge  of  a  fragiiient  may  transform 
a  simple  into  a  compound  fracture.  Fractures  of  the  nasal  bones  and 
of  the  base  of  the  skull  must  usually  be  regarded  as  compound  frac- 
tures, because  the  mucous  membranes  at  the  seat  of  the  fracture  are, 
as  a  rule,  torn. 

Fractures  produced  intentionally  in  operative  work  must  be  con- 
sidered as  a  special  class  of  compound  fractures.  A  bone  may  be 
sawn  or  chiselled  through  in  order  to  gain  room  for  operative  work 
(temporary  resection  of  the  mandible  in  removing  a  carcinoma  of 
the  tongue,  of  the  clavicle,  bones  of  the  skull,  ribs,  etc.).  Frequently 
long  bones  are  divided  ol)li([uely  or  a  cuneiform  piece  is  removed 
to  cori'ect  malformations  due  to  bowing  of  the  shaft  or  differences  in 
L'ugth. 

Fractures  associated  with  gunshot  wounds  form  another  class 
of  compound  fractures.  Complete  separation  of  the  extremities 
from  the  trunk,  such  as  occasionally  occurs  in  explosions,  machinery, 
and  railroad  accidents,  are  closely  related  to  compound  fractures 
(Klaul)er). 

The  same  principles  should  be  followed  in  examining  and  making  a 
diagnosis  of  a  compound   fracture  as  have  been  discussed   in   dealing 


596  THE   MECHANICAL   INJURIES 

with  simple  fractures.  It  is  a  great  mistake,  often  followed  by  second- 
ary infection,  to  probe  a  wound  associated  with  a  fracture  in  order 
to  determine  whether  it  is  superficial  or  extends  to  the  point  of 
fracture. 

Treatment. — In  serious  cases  the  treatment  should  first  be  directed 
to  counteracting  the  shock,  which  frequently  is  present  in  compound 
fractures,  to  controlling  the  haemorrhage,  and  to  preventing  infection. 
Von  Volkmann  maintained  that  the  first  dressing  .determined  the  fate 
of  the  patient  and  the  course  of  repair.  His  method  (which  consisted 
of  opening  the  wound  widely  and  sterilizing  it)  has  not  been  employed 
for  some  time,  von  Bergmann  having  shown  that  healing  frequently 
occurred  under  the  first  dry  dressing,  incision  of  the  parts  and  drainage 
having  been  omitted. 

Everyone  should  be  acquainted  with  the  general  principles  which 
control  the  application  of  the  fir.st  dressing,  for  in  this  way  severe  in- 
fections (which  so  often  develop  in  contused  and  lacerated  wounds)  may 
be  prevented.  The  wound  after  the  clothing  is  removed  should  be  cov- 
ered with  dry  aseptic  gauze,  or  in  case  of  emergency  with  fresh,  clean 
linen.  Some  sort  of  a  splint  should  then  be  applied  to  prevent  dis- 
placement of  the  fragments.  Hannorrhage  should  be  controlled  by  an 
Esmarch  constrictor  or  by  an  appropriate  bandage.  It  is  exceedingly 
dangerous  to  manipulate  a  compound  fracture,  to  sponge  out  or  irri- 
gate the  wound,  and  to  replace  protruding  fragments  unless  the  aseptic 
arrangements  are  very  complete. 

Acute,  progressive  suppurative,  and  gangrenous  infections  of  the 
soft  tissues,  pyogenic  infections  of  exposed  joints,  necrosis  of  bone, 
and  tetanus  may  be  caused  by  the  undue  zeal  of  some  good  but  ignorant 
Samaritan. 

The  patient,  after  being  undressed,  should  be  placed  on  an  operating 
table.  During  and  after  the  removal  of  the  emergency  dressing,  the 
limb  should  be  held  by  an  assistant  or  assistants.  The  wound  should 
then  be  carefully  protected  from  the  surrounding  parts  by  sterile 
towels.  If,  after  examination,  a  fracture  is  found,  an  anaesthetic  should 
be  administered.  Then  while  the  wound  is  protected  by  a  .sterile  dress- 
ing, the  surrounding  area  .should  be  sterilized.  The  larger  particles  of 
foreign  matter  should  then  be  rcMiioved  with  sterile  forceps,  the  smaller 
by  gentle  irrigation  of  the  wound  with  a  three  per  cent  solution  of 
hydrogen  peroxid  or  physiological  salt  solution. 

After  thorough  cleansing  of  the  wound  tlu^  fracture  is  reduced, 
and  if  it  is  thought  necessary  the  fragments  should  be  held  in  place 
by  a  bone  suture  or  some  other  device.  AVhenever  it  is  indicated, 
countci'-opcniiigs  .should  be  made  to  provide  foi-  di'ainage.  The  wound 
should    llicii    be    Iddscly    packed    with    iodoform    gauze,    which    ))rovides 


MECHANICAL   LNJl'RIJ<:S   OF   THE   DIFFERENT  TISSUES  597 

capillary  drainage,  A  plaster-of-Paris  bandage  should  then  be  ap- 
plied. A  fenestrum  should  l)e  eut  in  the  cast  over  the  avouikI  through 
which  the  dressings  can  be  changed  when  indicated.  In  favorable 
eases  the  Avound  may  be  partially  sutured  after  the  removal  of  the 
drainage. 

It  is  a  mistake  to  close  wounds  associated  with  compound  fractures 
completely,  for  then  an  oppoi'tnnity  is  afforded  the  bacteria  which  have 
been  carried  into  the  wound  to  develop.  The  mildest  forms  of  infec- 
tion may  then  become  exceedingly  virulent.  Tetanus  developed  in  two 
compound  fractures  which  w^ere  closed  by  suture  in  von  Bergmann's 
clinic. 

Innnediate  ampntation  may  be  indicated  if  the  soft  tissnes  al)out  the 
fractures  are  badly  crushed,  if  the  distal  part  of  the  extremity  is 
anaemic  and  no  pulse  can  be  felt,  rendering  it  probable  that  the  prin- 
cipal artery  has  been  destroyed.  Occasionally,  however,  ampntation  is 
indicated  later  even  Mhen  the  limb  can  be  saved,  because  of  the  con- 
tractures following  the  loss  of  large  areas  of  skin  and  the  laceration  of 
the  muscles.  If  an  extremity  is  torn  off  from  the  trunk,  the  vessels 
should  be  ligated,  the  projecting  fragments  cut  oft',  and  crushed  and 
contused  tissues  removed.  In  the  treatment  of  compound  fractures  of 
the  fingers  and  toes,  it  is  advisable  to  attempt  to  save  the  projecting 
phalangeal  fragment,  and  after  the  development  of  healthy  granulation 
tissue,  skin-grafting  can  be  resorted  to. 

It  may  be  necessary  to  incise  phk^gmons  which  develop  during  con- 
valescence. If  an  osteomyelitis  develops,  good  drainage  shonld  be  pro- 
vided, and  the  pieces  of  necrotic  bone  removed.  Suppurative  arthritis 
demands  drainage  of  the  joint,  resection  when  the  conditions  indicate 
it.  Amputation  may  be  necessary  because  of  a  general  infection  or 
tetanus. 

An  attempt  to  improve  the  function  of  the  part  should  be  made 
after  the  infection  has  subsided.  Extension  apparatus,  passive  motion, 
and  massage  may  be  employed  for  this  purpose.  Malposition  of  the 
fragments  and  anchylosis  are  frequent  when  the  patient  is  compelled 
to  remain  in  bed  for  some  time  because  of  the  poor  condition  of  the 
wound.  Not  infrequently  union  is  delayed  in  compound  fractures 
and  pseudarthrosis  is  common.  This  may  be  due  to  the  extensive 
destruction  of  the  periosteum,  to  infection,  necrosis,  or  resection  of  the 
fragments. 

LiTP^KATURE. — Albers,  v.  Bnrdeleben,  Korsch.  Ueber  Gehverbande.  Cliir.  Kongr.- 
Verhandl.,  1894,  II,  pp.  G3-93. — Bardenheaer.  Leitfaclen  dcr  Rehandlung  von  Frakturen 
und  Liixationen  der  Extremitaten  mittels  Feder-  resp.  Gewichtsextension.  Stuttgart, 
1890. — Bardenheaer  und  Grdssner.  Die  Rehandlung  der  Knochelbriiehe  niit  l*'.xtensions- 
verbanden   und   die   damit   erzielten   Resultate.     Kolner   Festschrift,  1904,  p.   113. — 


598  THE   MECHANICAL   INJURIES 

Bayer.  Ueber  Spiralbriiche  an  den  oberen  Extremitaten.  Deutsche  Zeitschr.  f.  Chir., 
Bd.  71,  1904,  p.  204. — Beely.  Zur  Behandlung  der  einfachen  Frakturen  der  Extremi- 
taten mit  Gips-Hanfschienen.  Konigsberg,  1878. — v.  Bergmann.  Erste  chirurgische 
Hilfeleistungen  an  Verungliickten,  in  Meyers  erste  arzliche  Hilfe,  Berlin,  1903.— Bier. 
Die  Bedeutung  des  Blutergusses  fiir  die  Heilung  des  Knochenbruches.  Med.  Klinik, 
Bd.  1,  Heft  1,  1905.—Bliesener.  Ueber  die  durch  die  Bardenheuersche  Extensions- 
methode  an  den  Briichen  der  unteren  Gliedmassen  exhaltenen  funktionellen  Ergebnisse. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  55,  1900,  p.  276. — Blohm.  Ueber  Vereiterung  sub- 
kutaner  Frakturen.,  I.-D.,  Berlin,  1898. — P.  Bruns.  Die  Lehre  von  den  Knochen- 
briichen.  Deutsche  Chir.,  Stuttgart,  1886. — Bum.  Die  Entwicklung  des  Knochenkallus 
unter  dem  Einflusse  der  Stauung.  Arch.  f.  klin.  Chir.,  Bd.  67,  1902,  p.  652. — Demisch. 
Ueber  Temperatursteigerungen  bei  der  Heilung  subkutaner  Frakturen.  I.-D.,  Zurich, 
1885. — V.  Eiselsberg.  Zur  Heilung  grosserer  Defekte  der  Tibia  durch  gestielte  Haut- 
periostknochenlappen.  Chir.  Kongr.-Verhandl.,  1897,  II,  p.  278; — -Die  heutige  Behand- 
lung der  Knochenbriiche.  Deutsche  Klinik,  Bd.  8,  p.  521,  Berlin,  1903. — Flatu. 
Muskelatrophien  nach  Frakturen,  etc.  Zentralbl.  f.  Grenzgeb.,  1902,  p.  305. — Franke. 
Behandlung  komplizierter  Frakturen.  Arch.  f.  klin.  Chir.,  Bd.  62,  1901,  p.  680. — 
Hdhnle.  Die  gerichtsarzliche  Beurteilung  schlecht  geheilter  Frakturen  und  Luxationen, 
wenn  in  Frage  steht,  ob  Kunstfehler  vorliegt.  Deutsche  Medizinalzeitung,  1903. — ■ 
Hdnel.  Ueber  Frakturen  mit  Bezug  auf  das  Unfallversicherungsgesetz.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  38,  1894,  p.  129. — Helferich.  Atlas  und  Grundriss  der  traumati- 
schen  Frakturen  und  Luxationen.  Miinchen,  Lehmann,  1903. — Hoffa.  Lehrbuch 
der  Frakturen  und  Luxationen.  Stuttgart,  Enke,  1904. — Jordan.  Die  Massagebe- 
handlung  frischer  Knochenbriicke.  Miinch.  med.  Wochenschr.,  1903,  p.  1148. — 
Jottkowitz.  Ueber  Heilungsresultate  von  Unterschenkelbriichen  mit  Bezug  auf  das 
Unfallversicherungsgesetz.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  42,  1896,  p.  610. — Klauber. 
Ueber  komplizierte  Frakturen  der  Extremitaten.  Beitr.  z.  klin.  Chir.,  Bd.  43,  1904, 
p.  319. — Fritz  Konig.  Ueber  die  Berechtigung  friihzeitiger  blutiger  Eingriffe  bei 
subkutanen  Knochenbriichen.  Arch.  f.  klin.  Chir.,  1905. — Kristinus.  Bericht  iiber 
130  Gehverbande.  Wien.  med.  Wochenschr.,  1902,  No.  51. — Loew.  Kondylenbriiche 
des  Kniegelenkes.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  44,  1897,  p.  422. — Lossen.  Grundriss 
der  Frakturen  und  Luxationen.  1897. — Lucas  Championniere.  Traitement  des  frac- 
tures par  le  massage  et  la  mobilisation.  Paris,  1895; — Quelles  sont  les  fractures  qui 
peuvent  etre  traitees  sans  appareil  inamovible  par  le  massage  et  la  mobilisation?  Resul- 
tats  de  ce  traitement.  Zentralbl.  f.  Chir.,  1900,  p.  1303.  13.  internat.  mediz.  Kongress, 
Paris.— Matos.  Remarks  on  some  Controverted  Questions  in  the  Treatment  of  Frac- 
tures. Zentralbl.  f.  Chir.,  1902,  p.  777. — W.  Milller.  Ueber  die  heutigen  Verfahren 
der  Pseudarthroscnheilung.  v.  Volkrnanns  Sannul.  klin.Vortr.,  No.  145,  1896. — Reichd. 
Zur  Behandhmg  schwerer  Forincn  von  Pseudarthrosis.  Chir.  Kongr.-Verhandl.,  1903, 
II,  p.  239. — Riedintjer.  Die  ambulatorische  Behandlung  der  Beinbriiche.  Wiirzburg. 
Abhandl.,  1902,  Bd.  2,  Section  9. — Swleck.  Zur  Altersatrophie  und  Inaktivitats- 
atrophie  der  Knochen.  Fortschr.  auf  dem  Gcbiete  der  Rontgenstrahlen,  Bd.  3,  1900. — ■ 
Valenzuela.  Erfolge  der  Behandlung  durch  Bewegung  imd  Massage  in  61  Frakturfiillen. 
Zentralbl.  f.  Chir.,  1901,  p.  666. — v.  Volkmann.  Die  Behandlung  der  komplizierten 
Frakturen.  Samml.  klin.Vortr.,  1877,  Nos.  1 1 7-118. — Die  Krankheiten  der  Bewegungs- 
organc.  In  Pitha-Billroths  Handb.  d.  Chir. — ./.  Wolff.  Ueber  die  AVechselbezie- 
huiigcn  zwischen  der  Form  uiid  der  Funktion.  Leipzig,  1!)01. — Wolkoiin'tsch.  Ueber 
die  \'on  mir  niigewandfcn  Behandlungsmethodcn  der  Briiche  der  grossen  Extreinitaten- 
kiK)clu'n,  etc.  Deutsche  Zeitschr.  f.  Vh'u:,  Bd.  63,  1902,  p.  2{Y.\.—7A('gler.  Ueber  das 
mikrosivophische  Verhalten  subkutaner  Briiche  langer '  Rohrenknochen.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  60,  1901,  p.  201, 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  599 

X.     INJURIES    OF    BODY    CAVITIES    AND    DIFFERENT    VISCERA 

These  injuries  may  be  subcutaneous  or  open;  naturally  the  two 
forms  are  frequently  combined. 

Subcutaneous  injuries  are  produced  by  blunt  force,  such  as  a  fall 
or  a  blow.  In  many  cases  the  symptoms  are  those  of  internal  haemor- 
rliage.  The  symptoms  may  differ  a  great  deal,  depending  upon  the 
organs  or  organ  injured. 

Ilamiatomas  of  the  cranial  cavity  following  lacerations  of  the  me- 
ningeal arteries  or  the  cranial  sinuses  give  rise  to  most  serious  symptoms. 
Iliemorrhage  from  the  middle  meningeal  artery,  associated  with  a  frac- 
ture of  the  skull  or  contusions,  is  especially  dangerous,  as  the  blood 
forces  its  way  between  the  dura  mater  and  the  skull,  giving  rise  to  the 
symptoms  of  brain  pressure  which  is  often  followed  by  death. 

Subcutaneous  injuries  of  the  abdomen  may  be  associated  with  the 
laceration  of  large  vessels  or  the  rupture  of  a  vascular  viscus.  So  much 
blood  is  then  lost  rapidly,  unless  the  haemorrhage  is  checked,  that  death 
soon  occurs.  The  dangers  of  ha?morrhage  into  the  chest  cavity  are  not 
so  great  as  those  of  pressure  exerted  by  the  extravasated  blood,  except 
when  the  heart  is  ruptured.  In  injuries  of  the  chest  haemorrhage  may 
occur  from  the  intercostal  and  internal  mammary  arteries,  from  the 
lung  which  has  been  pierced  by  a  fractured  rib,  or  from  some  of  the 
larger  vessels  about  the  heart. 

After  very  forceful  compression  of  the  abdomen  and  thorax,  an 
extravasation  of  blood  into  the  tissues  of  the  neck  and  head,  associated 
with  disturbances  of  vision,  may  occur.  According  to  Perthes,  Braun, 
and  Sick  the  extravasation  of  blood  in  these  cases  is  due  to  a  sudden  in- 
crease of  pressure  in  the  capillaries  with  subsequent  rupture  of  the 
same  as  the  result  of  the  rapid  increase  in  intrathoracic  pressure.  In 
these  cases  it  is  probable  that  the  lungs  are  distended  and  that  the 
glottis  is  involuntarily  or  reflexly  closed,  thus  preventing  escape  of  air 
from  the  lungs  when  the  pressure  is  exerted. 

Of  the  subcutaneous  injuries,  those  of  the  brain,  such  as  are  asso- 
ciated with  injuries  and  fractures  of  the  skull,  are  the  most  impor- 
tant. Contusions  and  lacerations  of  the  spinal  cord  accompany  frac- 
tures of  the  vertebra^.  Laceration  of  the  lung  and  rupture  of  the  heart 
may  be  associated  with  fractures  of  the  ribs.  The  same  lesions  may 
occur,  however,  without  fracture  of  the  bones  surrounding  these  organs. 
Subcutaneous  injuries  of  the  abdomen  may  be  associated  with  rupture 
or  extensive  laceration  of  the  liver  and  spleen  followed  by  fatal  haemor- 
rhage, or  with  rupture  of  the  stomach  and  intestine  followed  by  a 
rapidly  developing  fatal  peritonitis.  The  urinary  bladder  is  readily 
ruptured  Avhen   full,   if  a  blow   is  delivered   upon   the   abdomen.     In 


600  THE   MECHANICAL   INJURIES 

fractures  of  the  pelvis  the  bladder  may  be  lacerated  ])y  the  displaced 
fragments  of  bone.  The  kidney  may  be  torn,  lacerated,  or  completely 
separated  from  its  pedicle  as  a  result  of  a  subcutaneous  injury  of  the 
abdomen. 

Open  wounds  of  the  body  cavities  are  most  frequently  caused  hy 
knives,  stilettoes,  or  projectiles;  occasionally  by  sharp  pieces  of  iron, 
pickets,  canes  or  umbrellas,  axes  and  scythes.  Haemorrhage  and  infec- 
tion, which  latter  is  carried  in  with  the  vulnerating  force  or  develops 
after  rupture  of  a  hollow  viscus,  are  the  principal  dangers.  Extensive 
open  injuries  are  often  caused  by  explosions. 

The  symptoms,  diagnosis,  and  treatment  of  these  various  injuries  are 
fully  discussed  in  text-books  devoted  to  special  surgery. 

Literature. — v.  Bergmann,  v.  Bruns,  v.  Mikulicz.  Handb.  d.  prakt.  Chir.  Enke, 
Stuttgart,  2.  Aufl. — Kunig.  Lehrbuch  der  speziellen  Chirurgie.  Hirschwakl,  Berlin, 
8.  Aufl.,  1904. — Milner.  Die  sog.  Stauungsblutungen  infolge  Ueberdruckes  im  Runipf. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  76,  1905,  p.  85. — Perthes.  Ueber  ausgedehnte  Bhitex- 
travasate  am  Kopf  infolge  von  Kompression  des  Thorax.  Deutsche  Zeitschr.  f.  Chir. 
Bd.  50,  1899,  p.  436;— Ueber  Druckstauung.     Ebenda,  Bd.  55,  1900,  p.  384. 


XI.     GUNSHOT   WOUNDS 

Gunshot  wounds  demand  special  consideration.  They  may  be  caused 
by  firearms  of  small  caliber  or  by  artillery. 

WOUNDS    CAUSED    BY    FIREARMS    OF    SMALL    CALIBER 

Small  shot  and  ordinary  bullets  are  made  of  either  soft  or  chilled 
lead  and  are  round,  conical,  or  shaped  like  an  acorn.  The  bullets  used 
in  the  army  are  made  of  chilled  lead,  and  are  completely  or  partially 
jacketed  with  steel  or  some  other  metal.  Riiies  used  at  the  present  time 
are  of  much  smaller  caliber  (0.25"-0.31")  than  those  formerly  employed 
(0.44"^0.r)()"). 

Wound  of  Entrance  and  of  Exit — Wound  Canal. — Bullet  wounds  have 
a  wound  of  entrance,  a  canal,  and  if  the  projectile  perforates,  a  wound 
of  exit.  The  woiuid  of  exit  is  usually  lai-ger  than  the  wound  of  entrance, 
and  has  irregular,  jagged  outlines.  The  wound  canal  may  be  straight. 
The  projectile  when  partially  spent  may  be  deflected  by  bone  or  resist- 
ant tissue,  and  then  the  canal  will  be  curved.  The  diameter  of  the  canal 
corresponds  to  the  diameter  of  the  projectile.  The  canal  near  the  wound 
of  exit  may  be  funnel-shaped.  Under  certain  conditions  the  tissues  sur- 
rounding the  canal  are  lacerated.  This  is  especially  apt  to  be  tlu»  case 
when  the  projectile  has  a  high  explosive  force.  There  may  be  multiple 
wounds  when  a  bone  is  comminuted  and  the  fragments  are  driven 
111  rough  the  skin,  or  when  the  projectile  explodes. 


MECHANICAL   INJURIES   OF   THE   DIFFERENT   TISSUES  GOl 

The  form  of  a  gunsliot  wound  depends  upon  the  character  of  the 
projectile,  the  velocity  with  which  it  travels,  and  the  range  at  which 
the  projectile  is  fired.  Soft  projectiles  which  are  altered  in  form  or 
split  into  a  number  of  fragments  by  bone  or  resistant  tissue  cause  more 
extensive  wounds  than  hard  projectiles  or  those  which  are  partially  or 
completely  jacketed. 

Jacketed  bullets  do  the  most  damage  when  fired  at  a  range  of  about 
200  yards,  for  at  this  distance  the  small  caliber  projectile  has  a  high 
initial  velocity  and  great  potential  force.  Bullets  made  of  soft  lead  or 
soft  compounds  which  permit  of  mushrooming  when  they  come  in  con- 
tact with  solid  or  resistant  tissue  lacerate  the  tissues,  producing  enor- 
mous cavities  and  large  wounds  of  exit.  Because  of  this  mntilating 
action  the  use  of  the  soft-nosed  or  Dum-Dum  bullet  and  of  the  hollo w- 


Fio.  229. — Destkuctidx   i>f  the  Elbow  Joint  Caused  by  a  Lkad-i'oin  i  kd   (Dum-Dvm) 
Bullet  Fired  at  Close  Range. 

nosed  bullet  has  been  prohibited  by  the  International  Peace  Congress 
meeting  at  The  Hague.  The  form  of  even  a  completely  jacketed  bullet 
may  be  altered  by  striking  a  rock  or  some  other  very  hard  object  before 
it  enters  the  body. 

Powers  of  Penetration. — The  penetration  depends  upon  the  initial 
velocity  of  the  projectile  and  upon  its  potential  force  and  hardness. 
Small  pointed  projectiles  have  greater  penetrating  force  than  large 
round  ones.  The  full-jacketed  projectile  used  in  modern  rifles  has  a 
penetrating  power  which  enables  it  to  pass  through  a  number  of  bodies 
when  fired  at  a  range  of  from  600  to  1.000  yards.  It  therefore  pene- 
trates more  deeply,  lodges  less  fi'e(|uciitly,  causes  much  less  (lamag(\  and 
39 


G02 


THE   MECHANICAL   INJURIES 


has  smaller  wounds  of  entrance  and  exit  and  a  narrower  canal  than 
the  lead  bullets  which  were  formerly  used. 

Frightful  wounds  are  associated  with  siunshot  injuries  of  bones  and 
of  those  organs  which  contain  fluids  or  of  encapsulated  tissues  rich  in 
fluids,  such  as  the  skull,  the  heart,  the  full  stomach  and  intestines,  the 
liver,  spleen,  and  kidney.  The  greatest  damage  is  probably  inflicted 
when  the  projectile  is  fired  at  close  range  and  has  a  high  initial  velocity. 
The  mininuim  of  damage  is  inflicted  by  a  projectile  with  a  medium 
velocity,  while  a  bullet  which  is  well  spent  inflicts  a  little  more. 

The  symptoms  of  a  gunshot  wound  naturally  depend  entirely  upon 
the  tissues  or  the  viscera  which  are  injured.  Gunshot  wounds  of  the 
heart,  brain,  and  large  vessels  are  usually  fatal,  death  occurring  im- 
mediately or  soon  after  the  reception  of  the  wound. 

Symptoms  of  a  Gunshot  Wound. — The  first  symptom  is  usually  a  short 
sharp  pain.  The  pain  associated  with  wounds  inflicted  by  projectiles 
of  small  caliber  may  be  very  slight,  and  even  in  gunshot  wounds  of  the 


Fio.  2.30. — RoENTGEN-nAY  Picture  of  Fig.  229. 


abdomen  and  chest  it  is  frequently  compared  to  the  pain  associated  with 
a  wound  produced  by  a  small  stone.  The  impact  is  more  painful  when 
a  bone,  joint,  or  nerve  is  injured.  A  gunshot  wound  of  the  brain  causes 
unconsciousness,  of  the  spinal  cord  paralysis.  Sensation  is  rapidly 
lost  ill  the  tissues  about  a  gunshot  wound.  ,In  severe  injuries  the 
part  nl'  the  body  involved  may  be  cool,  pale,  incapable  of  motion,  and 


MECHANICAL    LNJUKIKS   OF   THE    DIFFERENT   TLS81IES  GOo 

without  sensation.  This  local  Avound  shock  may  pass  over  into  general 
shock. 

Hsemorrhage. — The  amount  of  ha-morrhage  varies.  The  smalh'r  the 
cutaneous  wound  and  the  narrower  the  canal,  the  less  marked  the  ex- 
ternal ha'morrhage  will  be.  The  canal  is  quickly  closed  by  clots,  and 
besides  the  tension  planes  in  the  tissue  differ,  so  that  when  the  tissues 
are  divided  the  canal  is  quickly  closed  by  their  overlapping.  The 
amount  of  external  hannorrhage  may  be  small,  even  when  large  vessels 
are  injured.  In  such  a  case,  however,  an  extensive  hu-matoma  may  form 
in  the  soft  tissues  and  in  the  body  cavities,  and  even  after  the  injury 
of  a  small  vessel  the  ha'morrhage  may  be  great  enough  to  cause  death. 
The  elastic  vessels  were  often  pushed  aside  and  escaped  injury  when 
the  old-style  lead  bullets  w^ere  used.  The  modern  small  steel- jacketed 
bullet  passes  directly  through  the  artery  or  cuts  it  oft*,  and  is  very 
apt  to  cause  severe  haemorrhage  (von  Bergmann).  When  the  wound  is 
small  internal  hamiorrhage  is  much  more  to  be  feared  than  external 
ha'morrhage  ( Kiittner ) . 

Y&iieties.— Gunshot  Wounds  of  the  Skin. — Gunshot  wounds  of  the 
skin  present  the  greatest  variety.  A  spent  bullet  causes  merely  a  con- 
tusion of  the  skin.  If  the  bullet  strikes  the  surface  of  the  body  ver- 
tically the  wound  of  entrance  wall  be  round.  It  will  correspond  in  size 
to  the  caliber  of  the  bullet.  A  wound  caused  by  a  steel-jacketed  bullet 
is  smaller  than  the  projectile,  as  the  pointed  nose  of  the  bullet  makes 
the  skin  tense  before  it  perforates.  The  margins  of  the  wound  are 
more  or  less  contused,  and  frequently  the  wound  itself  is  funnel-shaped. 
If  the  skin  lies  directly  over  bone  the  margins  of  the  wound  may  be 
everted,  and  in  this  case  the  wound  will  be  larger  than  w^hen  soft  tissues 
intervene  between  the  skin  and  bone.  If  the  projectile  has  been  fired 
at  very  close  range,  the  skin  surrounding  the  wound  will  be  burned  and 
filled  with  deeply  imbedded  grains  of  powder,  the  removal  of  which  is 
very  painful.  Some  of  the  superficial  grains  may  be  discharged  if  an 
artificial  inflammation  of  the  skin  is  produced  by  a  one  per  cent  subli- 
mate solution  (Hebra).  If  the  w^eapon  is  fired  at  very  close  range,  as  in 
attempts  at  suicide,  the  skin  or  mucous  membrane  may  be  badly  lacer- 
ated by  the  gases  formed  when  the  powder  explodes.  In  a  simple  gun- 
shot wound  of  the  soft  tissues  the  w^ound  of  exit  is  similar  to  the  wound 
of  entrance.  When,  however,  the  explosive  action  is  great,  the  wound 
of  exit  is  much  larger  than  the  wound  of  entrance,  and  has  notched, 
irregular,  and  undermined  edges  beneath  which  lie  shreds  of  tissue  and 
splinters  of  bone.  Large  gaping  wounds  of  exit  are  caused  by  lead 
bullets  of  large  caliber  and  by  partially  jacketed  bullets  fired  at  ranges 
varying  from  a  few  feet  up  to  200  yards. 

If  the  projectile  strikes  at  an  angle,  the  wounds  of  entrance  and  exit 


604  THE   MECHANICAL   INJURIES 

will  be  large  and  oval  or  irregular,  if  the  form  of  tlie  projectile  has 
already  been  altered  by  striking  some  hard  object.  Multiple  wounds 
of  entrance  and  exit  may  be  produced  by  the  modern  small-caliber 
projectile  if  it  perforates  different  parts  of  the  body,  cutaneous  folds, 
or  muscular  prominences. 

A  projectile  striking  the  body  tangentially  produces  long,  grooved 
wounds,  the  edges  of  which  are  undermined.  If  the  bullet  passes  just 
beneath  the  skin,  the  course  of  the  wound  canal  will  be  indicated  by 
ecchymoses. 

If  the  bullet  is  perfect  the  canal  will  be  smooth  and  narrow,  corre- 
sponding in  size  to  the  diameter  of  the  former.  If  the  bullet  is  fired  at 
short  range,  if  its  form  is  altered  by  coming  in  contact  with  bone,  or 
if  its  explosive  force  is  great,  the  tissues  along  the  wound  will  be  exten- 
sively lacerated  and  the  wound  of  exit  will  be  large. 

Injuries  of  Vessels. — Contusion  of  vessels  with  subsequent  necrosis 
of  their  walls  occurs  in  both  penetrating  and  perforating  gunshot 
wounds.  Small  arterial  wounds  caused  by  jacketed  bullets  are  much 
like  other  wounds  of  the  arterial  wall  and  end  in  scar  formation  with 
complete  healing  or  in  the  development  of  an  aneurysm.  An  arterio- 
venous aneurysm  may  develop  if  the  projectile  passes  between  an  ar- 
tery and  a  vein,  injuring  corresponding  parts  of  the  walls  of  both 
vessels. 

Injmnes  of  Nerves. — Complete  division  of  peripheral  nerves  is  more 
frequently  caused  by  large  lead  bullets  than  by  the  small  jacketed  ones. 
The  latter  may  penetrate  a  nerve,  merely  making  a  slit  in  it,  even  when 
the  nerve  is  of  the  same  diameter  as  the  bullet.  The  symptoms  of  an 
incomplete  paralysis  which  follow  such  an  injury  disappear  after  a 
few  weeks.  Neuralgia  and  neuritis  are  frequently  caused  by  a  bullet 
lodged  immediately  adjacent  to  a  nerve. 

Injuries  of  Bones. — A  bone  may  be  contused,  fractured,  or  perfor- 
ated by  a  projectile.  A  soft-lead  l)ullet,  the  form  of  which  is  easily 
altered,  when  traveling  with  but  little  velocity  becomes  flattened  out 
when  it  strikes  bone  and  causes  merely  a  contusion,  associated  with  an 
extravasation  of  blood  beneath  the  periosteum  and  into  the  bone  mar- 
row. Occasionally  the  projectile  does  not  perforate  the  skin,  merely 
contusing  the  latter  and  producing  a  subcutaneous  fracture. 

Jacketed  bullets  fired  at  close  range  perforate  spongy  bones  and  the 
ends  of  long  bones.  If  the  projectile  passes  at  right  angles  to  the  bone, 
it  produces  a  straight  canal,  the  wound  of  exit  being  larger  than  the 
wound  of  entrance.  If  it  strikes  tangentially,  a  groove  is  formed  in  the 
bone.  The  large  soft-lead  bullets  formerly  used  comminuted  and  fis- 
sured the  bones  and  lodged  in  the  spongiosa,  lacerating  it.  They  rarely 
perforated  the  l)one. 


MECHANICAL   INJURIES  OF  THE  DIFFERENT  TISSUES 


605 


The  diapliyses  of  loiiii'  bones  are  brittle  and  may  be  eonnuinuted  by 
both  the  jacketed  and  soft-lead  projectiles.  If  the  projectile  is  fired  at 
close  range  the  fragments  are  smaller  than  when  it  is  fired  at  long 
range,  but  the  extent  of  the  area  comminuted  is  the  same  (Fig.  229). 
The  typical  fracture  when  the  comminution  is  great  is  the  "  butterfly  " 
fracture,  in  which  two  lateral  fragments   (the  wings  of  the  butterfly) 


Fig.  231. — Fractures  of  the  Diaphysis  of  the  Humerus  Caused  by  a  Jacketed  Bullet. 
(After  Kuttner.)     a,  Close  range  (up  to  180  yards) ;  b,  long  range  (1,000-2,000  yards.) 

are  separated  by  two  fissures  passing  upward  and  downward  on  each 
side  of  the  wounds  of  entrance  and  exit.  If  the  projectile  does  not 
pass  through  the  greatest  diameter  of  the  bone,  the  resemblance  of  the 
fracture  to  the  form  of  a  butterfly  is  not  very  striking,  as  tlie  four 
fissures  have  an  irregular  course,  the  fragments  are  smaller,  and  are 


606 


THE  MECHANICAL   INJURIES 


displaced  more  (Fig.  230).  Fissures  associated  with  these  fractures 
frequently  extend  into  the  adjacent  joints.  Oblique  and  transverse  frac- 
tures may  be  caused  by  projectiles  grazing  a  bone. 

Relation  of  Destructive  Action  to  Range. — The  closer  the  range  the 
greater  will  be  the  laceration  of  the  tissues  surrounding  the  tract  of 
the  projectile.  Large  cavities  filled  with  blood,  fragments  of  soft  tis- 
sue, and  splinters  of  bone  Mdll  then  be  found.  The  cavities  behind  the 
perforated  bone  will  be  larger  than  those  in  front  of  it.  If  no  soft 
tissues  intervene  between  the  bone  and  the  skin,  the  wound  of  exit  is 


Fig.  232. — Gunshot  Wound  of  the  Lower  End  of  the  Right  Humerus  (1S66).  a,  Wound 
of  entrance  on  posterior  surface;  h,  wound  of  exit  anterior.  (Amputation  performed  by 
von  liangenbcck.) 


fre((uontly  quite  large,  corresponding  in  size  to  the  cavity  beneath  the 
skin  which  is  filled  with  detritus.  If  soft  tissues  intervene  between  the 
bone  and  the  skin,  the  wound  of  exit  will  be  of  about  the  same  size 
as  the  wound  of  entrance.  The  laceration  and  the  formation  of  cavities 
are  not  so  marked  when  the  projectile  (steel- jacketed  bullet  fired  at  a 
range  of  from  1,600  to  2,000  yards)  is  fired  at  long  range,  for  in  these 
cases  the  fragments  are  not  so  widely  separated,  and  some  of  them 
remain  attached  to  the  periosteum. 

Ounsliot   Wounds  of  Joints. — CJunshot  wounds  of  joints  are  almost 
always  complicated  by  fractures  of  the  ai'ticular  ends  of  the  bones  enter- 


MECHANICAL   INJURIES   OF   THE   DIFFERENT  TISSUES  607 

ing  into  the  formation  of  the  joint  involved.  Lead  bnllets  ahnost  always 
cause  extensive  comminution  of  the  bones  (Fig.  230).  The  small  lead 
bullets  discharged  from  the  ordinary  pistol  do  not  have  much  penetra- 
tion, and  frequently  they  become  imbedded  in  the  ligaments  or  enter 
the  joint  cavity  without  injuring  the  bones. 

Gunshot  Wounds  of  Body  Cavities  and  Viscera. — Of  gunshot  wounds 
of  the  body  cavities  and  viscera,  those  of  the  skull  and  its  contents  are 


Fig.  233. — Comminuted  Fracture  of  the  Tibia  (Battle  of  Schleswig,  1848). 
Resection  performed  by  B.  von  Langenbeck. 

the  most  dangerous.  Shots  fired  at  close  range  are  almost  always  fatal 
because  of  the  explosive  force  of  the  projectile,  which  is  especially 
marked  in  small-caliber  projectiles  used  in  warfare  at  the  present  time. 
The  brain  is  reduced  to  a  bloody  pulp,  and  occasionally  when  the  shot 
is  fired  at  very  close  ranges   (e.  g.,  in  attempts  at  suicide)   the  pulpy 


Fig.  234. — Gunshot  Wound  of  Head  of  the  Humerus  (Battle  of  Diippel,  1848).  Splintered 
fracture  of  the  head  of  the  humerus.  Long  head  of  the  biceps  divided  by  a  fragment  of 
bone.  Bullet  imbedded  in  the  bone.  Preparation  made  after  resection  by  B.  von 
Langenbeck. 

mass  is  driven  out  of  the  wound  of  exit  (Kronlein's  "  exenteratio 
cranii  ' ' )  and  the  skull  is  broken  up  into  a  countless  number  of  splinters. 
Projectiles  fired  at  middle  or  long  range,  or  those  traveling  with  but 
little  velocity,  may  fracture  or  penetrate  the  skull  and  become  lodged 
in  the  brain.  If  there  is  no  hamiorrhage  or  infection,  and  the  part 
of  the  brain  injured  does  not  control  some  vital  function,  such  a  bullet 


608  THE   MECHANICAL   INJURIES 

may  become  encapsulated  and  cause  but  little  or  no  interference  with 
the  functional  activity  of  the  organ. 

Gunshot  wounds  of  the  abdomen  are  especially  dangerous,  as  the 
projectile  may  lacerate  a  vascular  organ,  causing  a  fatal  haemorrhage, 
or  may  open  the  stomach,  intestine,  or  some  other  hollow  viscus,  causing 
a  fatal  peritonitis.  Spontaneous  healing  of  wounds  of  the  intestinal 
tract  occasionally  occurs  as  the  result  of  the  adhesions  forming  about 
the  opening  or  of  agglutination  between  the  tissues  surrounding  the 
opening  and  those  immediately  adjacent  to  it.  Spontaneous  healing 
occurs  more  frequently  after  wounds  caused  by  small  steel- jacketed  bul- 
lets than  after  those  caused  by  large  lead  bullets.  [In  penetrating  gun- 
shot wounds  of  the  abdomen  an  innnediate  laparotomy  should  be  per- 
formed. Tt  is  dangerous  to  delay  operation,  and  the  expectant  treatment 
should  be  discouraged.] 

Prognosis. — The  prognosis  of  gunshot  wounds  of  the  chest  is  good, 
except  when  the  heart  or  great  vessels  are  injured.  A  number  of  pa- 
tients, however,  die  later  as  the  result  of  suppurative  or  putrefactive 
inflammation  of  a  hemothorax.  Wounds  of  the  lungs  caused  by  pro- 
jectiles heal  rapidly.  Internal  haemorrhage  is  to  be  feared  only  when 
the  larger  pulmonary  vessels  are  injured,  or  when  the  lung  is  torn 
by  a  fragment  of  the  rib  carried  in  by  the  bullet  or  by  a  deformed 
projectile. 

WOUNDS    CAUSED    BY    ARTILLERY 

Wounds  produced  by  artillery  are  nuich  worse  than  even  the  most 
terrible  wounds  caused  by  j^rojectiles  of  small  caliber  when  fired  at 
close  range. 

Cannon  balls,  exploding  bombs  and  shells,  and  shrapnel  are  dis- 
charged by  artillery.  The  exploding  shells  are  filled  with  hollow  projec- 
tiles, and  when  they  explode  a  very  large  number  of  small  projectiles 
are  hurled  in  every  direction.  The  velocity  with  which  these  small  pro- 
jectiles travel  varies  from  450  to  1,000  yards  per  second.  Shrapnel  con- 
tains from  300  to  500  hard-lead  bullets  Aveighing  10  gm.  each.  These 
are  discharged  when  the  shell  strikes  or  explodes  during  its  flight  and 
have  a  greater  power  of  penetration  than  the  fragments  of  the  shell 
itself.  The  explosion  is  governed  by  a  time  fuse,  and  the  shell  can  be 
made  to  explode  in  front  of  or  above  its  mark. 

Bombs  and  the  so-called  indirect  projectiles  (fragments  of  stone  or 
splinters  of  Avood  hurled  when  the  projectile  strikes  or  explodes)  cause 
extensive  lacei*ations  and  contusions  which  may  be  seen  about  the  wounds 
of  entrance,  but  are  especially  marked  about  the  wounds  of  exit.  Pieces 
of  clothing  are  frequently  found  in  the  irregular,  ragged  wounds  of 
entrance,  and  shreds  of  nuisele,  lacerated  tendons,  nnd  spliiitcn-s  of  bime 


MECHANICAL   INJURIES   OP^  THE   DIFFERENT  TISSUES  609 

project  from  the  wounds  of  exit.  The  amount  of  injury  varies  with  the 
size  of  the  projectile  and  the  velocity  with  which  it  travels.  The  body 
cavities  may  be  opened  widely  or  an  extremity  torn  from  the  trunk 
by  a  large  projectile  traveling  with  great  velocity;  a  contusion  or  a 
groove  may  be  produced  by  a  spent  bullet. 

Fatal  internal  injuries,  deafness,  and  concussion  of  the  brain  may 
be  caused  by  the  explosion  of  a  shell  near  by  an  individual,  even  when 
he  is  not  struck  by  any  of  the  fragments.  The  explosive  force  may  be 
great  enough  to  hurl  him  against  a  tree  or  wall  causing  open  and  sub- 
cutaneous injuries. 

Wounds  caused  by  projectiles  fired  from  artillery  are  more  fre- 
quently fatal  than  are  those  caused  by  projectiles  of  small  caliber,  and 
are  more  frequently  accompanied  by  shock  and  severe  haemorrhage.  The 
dangers  are  also  increased  by  the  size  of  the  wounds  as  the  dangers  of 
infection  are  much  greater. 

CLmiCAL  COURSE   OF   GUNSHOT  WOUNDS  IN   GENERAL 

The  clinical  course  of  a  gunshot  wound  depends,  leaving  out  of  con- 
sideration ha?morrhage,  upon  the  position  of  the  wound  and  its  severity, 
upon  whether  infection  develops  or  not. 

Primary  infection  is  to  be  feared  but  little,  although  there  is  always 
abundant  opportunity  for  the  introduction  of  bacteria. 

It  has  been  determined  by  animal  experiments  that  a  bullet  may 
carry  infection  from  the  clothing  and  skin  into  the  deeper  tissues.  An 
animal  may  develop  a  fatal  infection  from  highly  virulent  bacteria 
attached  to  a  bullet  (A.  Miiller,  Koller).  Clinical  experience,  however, 
has  shown  that  the  infection  (unless  introduced  secondarily)  associated 
with  bullet  wounds  is  rarely  virulent,  and  that  the  bacteria  carried  in 
by  bullets  are  readily  destroyed  by  the  bactericidal  substances  in  the 
tissue  fluids.  Even  particles  of  clothing  may  be  encapsulated  in  the 
sensitive  lining  of  a  joint  without  causing  suppuration.  Clinically  the 
majority  of  bullet  wounds  are  to  be  regarded  as  not  infected,  unless 
secondar}^  infection  is  introduced  by  probing  and  improper  and  ill- 
advised  treatment.  Wounds  caused  by  blank  cartridges  are  an  excep- 
tion to  this  rule,  as  the  w'ads  which  are  shot  into  the  tissues  are  made 
of  rags  and  contain  in  many  instances  virulent  tetanus  bacilli. 

Secondary  Infection. — Secondary  infection  of  bullet  wounds  is  the 
greatest  danger.  It  occurs  most  frequently  in  wide,  gaping  wounds. 
The  smaller  the  wounds  of  entrance  and  exit,  the  less  the  dangers  of 
secondary  infection  and  the  more  rapid  the  repair.  Probing  for  the 
bullet,  exploration  of  the  wound  canal,  and  irrigation  of  the  wound 
with  antiseptic  solutions  are  dangerous,  for  bacteria  may  be  carried 
from  the  margins  of  the  wound  into  the  wound  canal,  and  the  resistance 


610  THE   MECHANICAL   INJURIES 

of  the  tissues  to  bacterial  invasion  may  be  reduced.  Almost  all  gunshot 
wounds  of  bones  and  joints  treated  by  the  earlier  methods  of  probing, 
irrigation,  and  exploring  the  wound  canal  were  associated  with  suppu- 
ration, general  infections  claiming  many  victims  if  early  amputations 
were  not  performed.  Von  Bergmann  was  the  first  to  advise  a  rational 
method  for  the  treatment  of  gunshot  wounds.  He  demonstrated  during 
the  Russo-Turkish  war  that  the  most  dangerous  injury — a  wound  of  the 
knee  joint — would  heal  without  infection  if  after  sterilization  of  the 
skin  surrounding  the  wound  a  dry  aseptic  dressing  were  applied. 

Diagnosis  and  Treatment. — The  diagnosis  is  based  upon  the  symp- 
toms associated  with  injuries  of  the  different  viscera  or  tissues.  An 
immediate  laparotomy  should  be  performed  in  gunshot  wounds  of  the 
abdomen,  if  it  is  probable  that  the  projectile  has  penetrated  the  abdomi- 
nal wall.  Bullet  wounds  of  the  chest  should  not  be  operated  upon  unless 
there  is  some  indication.  A  Roentgen-ray  picture  may  be  required  to 
determine  the  extent  and  type  of  an  injury  to  a  bone  or  the  position  of 
the  bullet. 

In  the  treatment  an  attempt  should  be  made  to  prevent  secondary 
infection,  and  to  provide  conditions  favorable  for  repair.  The  first- 
aid  dressing  is  very  important  in  preventing  secondary  infections.  The 
wound  should  be  covered  as  quickly  as  possible  with  sterile  gauze.  Each 
soldier  at  the  present  time  is  provided  with  an  emergency  dressing  which 
he  can  apply  himself.  This  dressing  is  so  made  that  it  can  be  easily 
applied  without  the  fingers  coming  in  contact  Mnth  the  layer  of  gauze 
resting  upon  the  wound.  In  hamiorrhage  from  large  vessels  of  the 
neck  and  trunk  which  cannot  be  controlled  by  an  Esmarch  constrictor, 
it  is  of  vital  importance  to  control  the  bleeding,  and  in  such  cases,  and 
in  these  only,  can  the  aseptic  dressing  of  the  wound  be  neglected. 

The  definitive  dressing  is  carried  out  according  to  the  principles 
already  given.  The  wound  is  protected  by  sterile  gauze  while  the  sur- 
rounding skin  is  being  shaved  and  sterilized.  Large  foreign  bodies 
are  then  removed  with  the  tissue  forceps,  small  particles  by  gentle  irri- 
gation with  physiological  salt  solution  or  a  three  per  cent  solution  of 
hydrogen  peroxid.  Shreds  of  tissue  and  loose  splinters  are  removed 
from  large  wounds,  spurting  vessels  are  caught  and  ligated,  and  counter- 
openings  are  provided  for  drainage  if  indicated.  Crusts  forming  on 
small  wounds  should  be  allowed  to  remain,  unless  there  is  some  indi- 
cation for  removal. 

Every  gunshot  wound  should  be  treated  by  the  open  method — that  is, 
it  should  not  be  closed  by  plaster  oi-  sutures.  Dry  aseptic  gauze  serves 
a  double  purpose  as  a  dressing  for  these  wounds:  (1)  It  absorbs  secre- 
tion; (2)  it  protects  the  wound  from  outside  infection.  By  this  dress- 
ing the  small  wounds  of  entrance  and  exit,  aiul  even  the  larger  wounds 


MECHANICAL   INJURIES  OF   THE   DIFFERENT  TISSUES  611 

situated  in  cavities  filled  with  lacerated  tissue,  fractured  bones,  and 
injured  joints,  are,  as  it  were,  transformed  into  simple,  subcutaneous 
wounds.  This  is  not  the  case  in  very  large  wounds.  In  some  of  these  it 
is  not  always  possible  to  prevent  severe  infections  even  Avhen  all  the 
recesses  are  carefully  tamponed  and  good  drainage  is  provided.  In 
these  cases  phlegmons  may  develop ;  secondary  Ini'morrhages  may  occur 
from  injured  blood  vessels;  infections  of  bones  and  joints,  or  tetanus 
may  develop.  If  these  complications  develop,  incisions,  resections, 
amputations,  and  ligations  should  be  performed  when  indicated.  Am- 
putations are  more  frequently  performed  in  military  than  in  civil 
practice.  Time  and  facilities,  which  render  successful  conservative 
treatment  possible,  are  often  wanting  during  the  stress  of  battle.  The 
experiences  of  the  Russo-Turkish,  the  Boer,  and  Spanish-American  wars 
indicate  that  there  is  a  decreasing  demand  for  mutilating  operations 
in  the  treatment  of  gunshot  wounds. 

Bidlets,  fragments  of  stones,  splinters  of  wood,  etc.,  if  they  are  seen 
in  the  wound  or  are  felt  directly  beneath  the  skin,  should  be  removed. 
They  should  also  be  removed  if  an  infection  preventing  encapsulation 
develops,  if  they  cause  pain  or  interfere  with  function  after  they  have 
become  encapsulated. 

If  possible  the  wounded  part  should  be  put  at  rest  by  an  immobiliz- 
ing dressing,  so  that  wound  lepair  will  not  be  interfered  with  by  move- 
ments. Naturally,  innnobili/ation  should  be  employed  when  bones  are 
fractured,  but  it  is  also  of  value  in  treating  gunshot  wounds  of  tendon 
sheaths  and  of  muscles. 

Laparotomy,  combined  with  intestinal  suture  if  the  gastrointestinal 
tract  is  perforated,  and  trephining  of  the  skull  to  remove  splinters 
of  w^ood,  elevate  a  depressed  fragment  or  to  control  ha'morrhage  are 
indicated  in  gunshot  wounds  of  the  abdomen  and  skull.  A  kidney  or 
the  spleen  may  be  so  badly  lacerated  that  extirpation  of  the  injured 
viscus  is  indicated.  As  a  rule,  the  expectant  treatment  is  more  fre- 
quently employed  in  military  than  in  civil  practice,  as  the  conditions 
existing  in  the  former  do  not  always  permit  of  extensive  operative 
interference,  and  besides,  spontaneous  healing  occurs  more  frequently 
in  wounds  caused  by  projectiles  of  snuill  caliber  that  are  used  in  war. 

The  first-aid  treatment  consists  of  covering  the  wound  with  sterile 
gauze ;  in  applying  an  Esmarch  bandage  to  control  hannorrhage ;  of  sup- 
plying stimulants  wdien  the  patient  is  suffering  from  shock  or  has  lost 
consciousness,  and  of  introducing  a  tracheotomy  tube  or  a  tracheal 
canula  after  injury  of  the  larynx  or  trachea  (von  Bergmann). 

The  first  dressing  should  be  applied  upon  the  battlefield,  where,  in 
addition  to  adjusting  permanent  dressings  and  preparing  the  wounded 
for  transportation,  more  serious  operations,  such  as  the  ligation  of  arter- 


612  THE  MECHANICAL   INJURIES 

ies  and  amputations,  may  be  performed  when  indicated.  It  may  also  be 
necessary  to  perform  a  urethrotomy  in  gunshot  wounds  of  the  peri- 
neum and  pelvis  or  a  tracheotomy  in  gunshot  wounds  of  the  neck  when 
there  is  interference  with  breathing  (von  Bergmann).  All  other  opera- 
tions should  be  performed  in  the  field  hospitals,  of  which  each  army 
corps  has  twelve  with  accommodations  for  200  each  (Schjerning). 

Literature. — -v.  Bergmann.  Die  Behandlung  der  Schusswunden  des  Kniegelenks 
im  Kriege.  Stuttgart,  1878; — Erste  Hilfe  auf  dem  Schlachtfelde  und  Asepsis  und 
Antisepsis  im  Kriege.  Aerztl.  Kriegswissenschaft,  Jena,  1902. — v.  Bruns.  Ueber  die 
kriegschirurgische  Bedeutung  der  neuen  Feuerwaffen.  Chir.  Kongr.-Verhandl.,  1892, 
I,  p.  1; — Inhumane  Kriegsgeschosse.  Chir.  Kongr.-Verhandl.,  1898,  II,  p.  317; — 
Ueber  die  Wirkung  der  Bleispitzengeschosse.  Beitr.  z.  khn.  Chir.,  Bd.  21,  1898,  p.  825. 
— V.  Coler  und  Schjerning.  Ueber  die  Wirkung  und  kriegschirurgische  Bedeutung  der 
neuen  Handfeuerwaffen.  Mediz.  Abteil.  des  kgl.  preuss.  Kriegsministeriums,  1894. — 
Fischer.  Handbuch  der  Kriegschirurgie.  Deutsche  Chir.,  1882. — Flockemann,  Ringel, 
Wieting.  Kriegserfahrungen  aus  dem  siidafrikanischen  Kriege.  v.  Volkmanns  Samml. 
klin.  Vortr.,  1901,  Nos.  295-296. — Hildehrandt.  Zur  Erklarung  der  Explosionsschiisse. 
Miinch.  med.  Wochenschr.,  1903,  No.  25,  p.  1061 ; — Zur  Erklarung  der  Bewegungs- 
vorgange  bei  Explosionsschiissen.  Arch.  f.  klin.  Chir.,  Bd.  72,  1904,  p.  1050. — Kuyser. 
Experimentelle  Studien  iiber  Schussinfektion.  Beitr.  z.  klin.  Chir.,  Bd.  26,  1900,  p.  282. 
— Kocher.  Zur  Lehre  von  den  Schusswunden  durch  Klienkalibergeschosse.  Kassel, 
1895. — R.  Kohler.  Die  modernen  Kriegswaffen.  Berlin,  1897. — Konig.  Schussver- 
letzungen  am  Rumpfe,  insbesondere  am  Thorax.  Aerztl.  Kriegswissenschaft,  Jena, 
1902. — -Kranzf  elder  und  Schwinning.  Die  Funkenphotographie,  insbesondere  die 
Mehrfachfunkenphotographie  in  ihrer  Verwendbarkeit  zur  Darstellung  der  Geschossi- 
wirkung  im  menschl.  Korper.  Mediz.  Abteil.  d.  kgl.  preuss.  Kriegsministeriums,  Berlin, 
Juni,  1903. — KilUner.  Kriegschirurgische  Erfahrungen  aus  dem  siidafrikanischen 
Kriege,  1899-1900.  Beitr.  z.  klin.  Chir.,  Bd.  28,  1900,  p.  lll.—Mohr.  Schussverletz- 
ungen  durch  kleinkalibrige  Gewehre,  speziell  nach  den  Erfahrungen  der  letzten  Feldziige. 
Arch.  f.  klin.  Chir.,  Bd.  63,  1901. — Pirogojf.  Grundziige  der  allgemeinen  Kriegschirurgie. 
Leipzig,  1864. — Reger.  Ueber  die  kriegschirurgische  Bedeutimg  der  neuen  Feuerwaffen. 
Chir.  Kongr.-Verhandl.,  1892,  II,  p.  19; — Die  Kronleinschen  Schadelschiisse.  Ibid., 
1901,  II,  p.  508. — Schjerning.  Die  Organisation  des  Sanitatsdienstes  im  Kriege. 
Aerztl.  Kriegswissenschaft,  Jena,  1902,  p.  229; — Ueber  die  Bekampfvmg  des  Tetanus  in 
der  Armee.  Veroffentl.  aus  d.  Geb.  d.  Militarsanitiitsw.  Berlin,  1903,  Heft  23. — Schjer- 
ning, Thole  und  Voss.  Die  Schussverletzungen.  Fortschr.  auf  d.  Geb.  d.  Rontgen- 
strahlen.  Erganzungsband  7,  1902. — Schloffer.  Ueber  embolische  Verschleppung 
von  Projektilen.  Beitr.  z.  klin.  Chir.,  Bd.  37,  1903,  p.  ms.—Seydel.  Lehrbuch  der 
Kriegschirurgie.  Stuttgart,  1905. — Skrzeczka.  Aus  der  gerichtsiirzlichen  Praxis 
(Platzwunden).     Vierteljahrsschr.  f.  gerichtsarztl.  Mediz.,  Bd.  10. 


II,     CHEMICAL    INJURIES 

Chemical  substances  which  by  their  action  cause  death  and  degen- 
eration of  tissues  are  called  caustics.  They  are  frequently  employed  in 
surgery.  Alkalies,  such  as  sodium,  potassium,  and  calcium;  acids,  such 
as  hydrochloric,  sulphuric,  nitric,  arsenious,  chromic,  and  carbolic;  and 
tlu'  salts  of  some  metals,  such  as  silver  nitrate,  zinc  chlorid,  and  copper 
sulphate,  are  the  most  common  typas  of  caustics.  The  alkalies  and  me- 
tallic salts  act  by  uniting  with  the  albumens  in  the  tissues;  the  acids 
by  burning  the  structures  with  which  they  come  in  contact. 

Action  of  Caustics. — Dilute  and  mild  caustics,  when  applied,  cause 
;ni  inflammatory  reaction.  An  erythema  and  vesicles  develop,  and  the 
clinical  picture  of  the  lesion  corresponds  to  that  of  a  burn  of  the  first  or 
second  degree.  Necrosis  followed  by  eschar  formation  is  caused  by  strong 
caustics,  the  necrosis  involving  tissues  at  various  depths,  depending  upon 
the  strength  of  the  caustic  and  the  time  it  is  allowed  to  act.  The  skin  is 
less  easily  destroyed  by  caustics  than  is  mucous  membrane. 

Acetic  acid  always  has  a  superficial  action,  while  the  alkali  caustics 
penetrate  more  deeply.  Various  caustics,  such  as  arsenious,  chromic, 
and  lactic  acids,  ammonia,  and  copper  sulphate,  act  only  upon  mucous 
membranes.    Zinc  chlorid  has  no  effect  upon  healthy  skin. 

Those  agents  are  best  suited  for  cauterization  which,  lilce  concen- 
trated sulphuric  and  fuming  nitric  acid  and  silver  nitrate,  penetrate  to 
the  deeper  layers  of  the  skin  and  mucous  membranes  only  after  acting 
for  some  time.  For  this  reason  nitric  acid  is  frequently  applied  to 
superficial  hfcmangiomas,  while  exuberant  and  diseased  granulation  tis- 
sue is  destroyed  by  silver  nitrate.  Chromic  acid  is  recommended  by 
Czerny  for  the  treatment  of  inoperable,  malignant  tumors,  the  ulcerated 
surfaces  being  covered  with  gauze  saturated  with  from  a  twenty  to 
fifty  per  cent  solution.  Lactic  acid  (fifty  to  eighty  per  cent)  is  fre- 
quently employed  in  the  treatment  of  tuberculosis  of  nmcous  membranes. 

Symptoms  of  Cauterization. — The  pain  following  the  application  of  a 
caustic  is  sometimes  transitory'  (e.  g.,  after  nitric  acid  or  silver  nitrate)  ; 
at  other  times  it  persists  for  some  time  (e.  g.,  after  concentrated  car- 
bolic acid  and  caustic  calcium).  After  a  caustic  is  applied  a  white, 
yellowish  brown,  or  brown  spot  develops  which,  upon  the  skin,  rapidly 

613 


614 


CHEMICAL   INJURIES 


becomes  transformed  into  a  dry  hard  crust ;  upon  the  mucous  membranes 
into  a  discolored  soft  one.  Gradually  this  crust  or  eschar  is  separated 
from  the  healthy  surrounding  parts  by  granulation  tissue.  Naturally 
a  superficial  eschar  is  separated  more  rapidly  than  a  deep  one.  Several 
weeks  may  be  required  for  the  separation  of  a  layer  of  bone  which  has 
been  killed  by  a  caustic.  Severe  haemorrhage  may  occur  during  the 
separation  of  an  eschar,  for  the  walls  of  a  large  vessel  may  have  under- 
gone necrosis. 

In  Fig.  235  is  represented  the  face  of  a  man  over  whom  caustic  soda 
was  thrown.     lie  was  brought  to  the  clinic  with  large  yellow  crusts 

covering  the  entire  face, 
both  ears,  the  forehead, 
and  temples.  These  crusts 
separated  in  two  weeks, 
good  healthy  granulation 
tissue  which  was  skin- 
grafted  having  developed. 
After  a  number  of  weeks 
several  sequestra  were  dis- 
charged from  the  frontal 
bone.  Granulation  tissue 
which  covered  the  remains 
of  the  bulb  of  the  eye  de- 
veloped rapidly  from  the 
%"  remnants  of  the  left  eye- 
lid. This  tissue  was  soon 
covered  by  epithelium 
Avhich  developed  from  that 
still  attached  to  the  eye- 
lids. An  open  space  in  which  an  everted  conjunctiva  may  be  seen  indi- 
cates tlie  position  of  the  right  palpebral  fissure. 

Scars  Following  Cauterization.^ — The  scars  which  remain  after  super- 
ficial cauterization  are  smootli  and  soft.  Sears  following  the  separation 
of  deep  eschars  of  the  skin  are  inclined  to  the  formation  of  keloidlike 
growths,  and  to  cause  the  distortion  of  the  parts  which  in  the  face  may 
lead  to  narrowing  of  the  natural  orifices  or  to  ectropion  of  the  eye- 
lids and  lips. 

Cauterization  of  the  a'sophagus  and  urethra  may  be  followed  by 
serious  results,  as  the  masses  of  scar  tissue  which  develop  may  narrow 
or  occlude  their  luiniiia.  Acids  and  lye  swallowed  accidentally  or  taken 
with  suicidal  intt'iil  l)iiiti  Ihc  stomach  as  well  as  the  o'sophagus.  If 
perforation  ending  I'alally  docs  not  occur,  the  _scar  tissue  which  de- 
velops later  may  narrow  the  (rsophagus  or  cause  a  stenosis  of  the  car- 


FiG.   235. 


CHEMICAL   INJURIES  615 

iliac  and  pyloric  openings  of  the  stomach.  Injuries  of  the  urethra  are 
caused  most  frecpiently  by  the  use  of  strong  solutions  of  acids  or  silver 
nitrate  in  attempts  to  abort  a  beginning  gonorrhea. 

The  nature  of  an  eschar  of  the  skin  following  cauterization  is  usu- 
ally readily  recognized.  The  reaction  of  the  reagent  can  be  determined 
in  recent  cases  by  the  use  of  litmus  paper.  The  statement  of  the  patient 
is  of  value  in  determining  the  nature  of  the  caustic,  except  in  hysterical 
pati(»nts  who  not  infrequently  deliberately  injure  themselves. 

Treatment. — The  treatment  of  chemical  injuries  in  recent  eases 
shoukl  be  directed  toward  neutralization  of  the  agent  before  it  pene- 
trates deeply.  Chemists  and  apothecaries  are  most  frecpiently  injured, 
and  they  usually  have  two  solutions  ready.  Acetic  acid  or  vinegar  is 
used  to  neutralize  the  alkalies,  while  a  solution  of  sodium  bicarbonate 
is  used  to  neutralize  the  acids.  In  some  cases  these  agents  are  employed 
too  late,  the  damage  having  already  been  done  by  the  caustic. 

If  the  tissues  have  already  been  destroyed,  nothing  can  be  done  but 
to  hasten  the  separation  of  the  eschar  by  moist  dressings,  or  to  lessen 
the  pain  and  prevent  infection  by  the  use  of  ointments.  Cicatricial 
stenosis  of  the  oesophagus,  pylorus,  and  urethra  should  receive  appro- 
priate surgical  treatment.  Large  granulating  wounds  should  be  skin- 
grafted. 

Literature. — Arnd.    Aetzmittel,  Aetzwunden.    Kochers  Realenzyklopadie.    Son- 
nenberg.    Verbrennungen  and  Erfrierungen.    Deutsche  Chir.,  1879,  atzenile  Stoffe,  p.  L3. 


III.    THERMAL    INJURIES 
CHAPTER    I 

FREEZING 

Cold  acting  upon  the  body  produces  local  and  general  changes  which 
are  grouped  under  the  term  of  freezing.  The  degree  of  the  pathological 
changes  depends  upon  the  character  and  degree  of  the  cold,  the  length 
of  time  that  it  acts,  and  upon  the  resistance  of  the  organism  or  the  part 
involved. 

It  is  a  well-known  fact  that  moist  cold  acts  more  rapidly  and  severely 
than  dry  cold,  and  that  a  much  lower  degree  of  cold  can  be  borne  when 
there  is  no  wind  than  when  it  is  blowing  strongly.  Powerful  healthy 
men  are  more  resistant  to  cold  than  are  weak,  anaemic  individuals  and 
children  and  old  people. 

General  Freezing. — Symptoms. — General  freezing  begins  with  severe 
and  repeated  rigors  and  a  feeling  of  lassitude,  gradually  passing  into  a 
desire  to  sleep  which  cannot  be  resisted.  If  the  individual  cannot  resist 
this  desire  to  sleep,  he  falls  in  the  snow  or  ice  and  dies.  Drunken  per- 
sons, children  and  old  people,  and  anaemic  individuals  succumb  most 
frequently  and  rapidly  to  freezing.  If  the  individual  has  strength 
enough  to  resist  the  desire  to  sleep,  he  may  keep  on  his  way  until  he 
finds  shelter  or  is  rescued  by  friends  or  passers-by.  As  freezing  pro- 
gresses the  individual  reels  like  a  drunken  man,  the  senses  become 
numbed,  consciousness  is  lost,  the  pulse  and  respiration  are  slowed. 
Finally  he  collapses  and  rapidly  dies  of  cardiac  weakness  and  cerebral 
anannia,  or  remains  alive  for  a  longer  time  (sometimes  for  days),  event- 
ually dying,  the  entire  body  becoming  stiff,  as  the  result  of  the  freezing 
of  the  tissue  fluids. 

If  the  rectal  temperature  of  the  frozen  individual  is  not  below  68°  F. 
when  he  is  found,  there  is  a  possibility  of  resuscitating  him,  even  if  his 
cardiac  and  respiratory  functions  are  weak.  The  convalescence,  how- 
ever, is  usually  slow  in  these  eases,  and  is  often  accompanied  by  nervous 
symptoms  (headache,  loss  of  consciousness,  delirinni,  paralysis).  Death 
may  occur  even  wlicii  convalescence  seems  to  ])e  fairly  well  established, 
616 


FREEZING  617 

as  the  result  of  degenerative  changes  in  the  blood  cells  and  cardiac 
weakness. 

Treatment. — In  the  treatment,  the  results  of  which  are  always  doubt- 
ful, an  attempt  should  be  made  to  restore  gradually  warmth  to  the 
frozen  body  and  to  aid  the  circulation.  A  sudden  change  into  a  warm 
room  is  always  dangerous,  because  of  the  damage  done  to  the  tissues 
by  thawing  them  out  rapidly  and  because  of  the  sudden  entrance  of  a 
large  number  of  degenerating  red  blood  corpuscles  into  the  circulation. 

The  frozen  individual  should  not  be  brought  immediately  into  a 
heated  room,  but  should  be  detained  in  a  cold  room,  the  temperature  of 
which  registers  34°  or  35°  F.  The  entire  body  should  be  rubbed  with 
snow  or  cold  cloths  in  order  to  stinudate  the  cutaneous  blood  vessels. 
Camphorated  oil  should  be  injected  to  stinuilate  the  heart,  and  the 
respiratory  activity  should  be  aided  by  artificial  respiration  carefully 
induced;  The  patient  should  then  be  placed  in  a  bath  of  a  temperature 
of  60°  F.  This  temperatui-e  should  be  gradually  raised  Avithin  three 
hours  to  86°  F.  As  soon  as  the  patient  can  swallow  he  should  be  given 
warm,  stimulating  drinks  and  nourishment.  Frequently  morphin  is 
required  to  control  the  pain  in  the  frozen  part. 

Local  Freezing. — Local  freezing  affects  most  frequently  those  parts 
which  are  not  protected  by  clothing  and  those  in  which  the  circulation 
is  interfered  w'ith  by  tight  and  constricting  articles  of  wearing  apparel 
(gloves  and  boots).  The  ears,  nose,  cheeks,  fingers,  and  toes  are  most 
frequently  frozen. 

Degrees  of  Frosthites. — Local  freezing  (frostbite)  is  usually  di- 
vided into  three  degrees,  depending  on  the  severity,  but  often  a  sharp 
distinction  between  the  different  degrees  cannot  be  made. 

The  first  degree  is  characterized  by  a  transitory  hypera-mia,  the  sec- 
ond by  the  formation  of  vesicles,  and  the  third  by  gangrene.  Fremmert 
and  Luppian  divide  the  third  degree  into  three  subdivisions,  depending 
upon  the  extent  of  the  gangrene  (gangrene  of  the  superficial  layers  of 
the  skin,  of  the  cutis  and  subcutaneous  tissues,  and  of  all  the  tissues 
down  to  the  bone).  If  we  accept  this  classification,  we  mu^t  recognize 
five  degrees  of  local  freezing  or  frostbite.  Chill)]ains  foi-m  a  pecidiar 
chronic  form  of  local  freezing. 

(a)  First  Degree  of  Frostbite. — The  first-degree  frostbite  is  the  most 
common  and  mildest.  It  follows  relatively  short  exposure  to  severe  cohl 
and  is  characterized  by  erythema  and  swelling,  which  develop  as  soon 
as  the  frozen  part  is  warmed.  The  frozen  part  loses  sensation,  after  a 
slight  preliminary  pain,  and  becomes  pale  following  contraction  of  the 
blood  vessels.  When  a  frozen  part  is  warmed  it  becomes  hyperaemic 
and  oedematous,  as  a  result  of  the  dilatation  of  the  vessels.  The  ery- 
thema and  ana'sthesia  may  persist  for  some  time,  rarely  longer  than  ten 
40 


618  THERMAL   INJURIES 

days,  the  length  of  time  usually  depending  upon  how  long  the  ana'inia 
persisted.  An  ugly  redness  of  the  point  of  the  nose  and  of  the  margins 
of  the  ears,  resulting  from  a  permanent  dilatation  of  the  blood  vessels, 
often  persists  after  frostbites  of  these  parts. 

(&)  Second-Degree  Frostbites. — In  frostbites  of  the  second  degree 
the  deep  red  or  violet,  cold  and  insensitive  skin  becomes  covered  with 
blebs  or  vesicles.  There  is  a  stasis  of  blood  in  the  small  cutaneous  veins, 
as  a  result  of  the  contraction  of  the  small  arteries,  ior  there  is  not  force 
enough  to  drive  the  blood  into  the  larger  veins.  Transudation  of  the 
blood  plasma,  resulting  in  an  oedema  and  the  formation  of  blebs,  fol- 
lows the  stasis.  When  the  circulation  is  reestablished  sensation  returns 
and  the  blebs  dry  to  form  crusts,  beneath  which  healing  occurs  without 
scar  formation.  If  the  blebs  burst  and  become  infected,  painful  ulcers 
form  which  become  chronic  if  an  oi'dema  persists. 

(c)  Third-Degree  Frostbite. — The  third  degree  of  frostbite  is  char- 
acterized by  gangrene  or  the  formation  of  an  eschar.  The  tissues  die 
if  they  are  so  nuich  damaged  that  they  cannot  react  wdien  treatment  is 
instituted,  and  if  the  large  arteries  within  the  frozen  area  and  at  its 
boundaries  are  closed  by  thrombi.  The  frozen  part  is  rigid.  The  tip 
of  the  nose  and  the  margins  of  the  ears  may  become  so  brittle  that 
they  may  be  broken  off  like  a  piece  of  glass.  When  such  a  part  is 
warmed,  only  the  symptoms  of  the  second-degree  frostbite — oedema,  cya- 
nosis, and  vesicles — are  present  at  first.  The  part,  however,  remains 
cold,  blue,  and  without  sensation,  as  the  circulation  is  not  reestablished. 
After  some  days  the  large  shreds  of  skin  and  the  nails  become  loosened, 
and  dark  brown  crusts  begin  to  appear  upon  the  frozen  part.  Later 
dry  gangrene  develops,  and  a  line  of  demarcation  separating  the  living 
from  the  dead  forms.  Gangrene  occurs  frequently  when  treatment  is 
instituted  late. 

The  three  degrees  of  frostbites  are  often  associated  when  large  areas 
or  many  different  parts  are  involved.  The  effects  are  not  the  same  in 
different  parts,  the  protected  ones  presenting  the  milder  changes,  the 
unprotected  the  severer.  The  severest  cases,  associated  with  freezing  of 
the  four  extremities  and  of  different  parts  of  the  face,  are  accompanied 
by  general  symptoms.  An  accurate  diagnosis  as  to  the  degree  of  the 
pathological  changes  cannot  be  made  within  the  first  few  hours,  as  fre- 
(picntly  they  do  not  become  pronounced  until  after  some  days. 

The  general  condition  of  the  patient  is  not  impaired  in  local  freez- 
ing proper,  unless  infection  develops  from  the  vesicles,  from  the  necrotic 
foci,  from  the  ulcers,  or  from  the  zone  of  demarcation. 

Seqiielce. — Long-continuing  cyanosis  and  oedema,  associated  with 
painful  ulcers,  crippled  fingers  and  toes,  deep  defects  in  the  soft  tis- 
sues, and  disfiguring  culaiicous  scars,  ai'e  not  the  only  results  of  frost- 


FREEZING  619 

biles.  Transitory  or  permanent  paralysis  of  different  nerves,  myoge- 
nous contractures  resulting  from  a  waxy  degeneration  and  destruction 
of  the  contractile  substance,  and  proliferation  of  the  intima  of  the  ves- 
sels with  subsequent  nutritional  disturbances  ending  in  the  formation 
of  ulcers  and  gangrene  are  some  of  the  other  sequels. 

Treatment. — In  treating  frostbites,  the  temperature  should  be  grad- 
ually restored,  as  in  general  freezing.  The  rapid  restoration  of  tempera- 
ture is  very  painful  and  dangerous,  as  sudden  thawing  out  of  frozen 
tissues  causes  profound  nutritional  disturbances. 

In  the  milder  degrees  of  frostbites,  rubbing  with  snow  or  particles 
of  ice  is  the  common  method  of  relieving  the  anemia. 

In  the  severer  degrees  the  dangers  of  gangrene  should  be  avoided  by 
relieving  as  quickly  as  possible  the  venous  stasis.  The  most  important 
method  for  this  purpose,  which  was  introduced  by  von  Bergmann,  is 
vertical  suspension  of  the  frozen  member,  to  which  a  well-fitting  immo- 
bilizing splint  has  been  applied.  Frequently  the  swelling  subsides  rap- 
idly, and  the  bluish  discoloration  disappears  when  this  method  is  em- 
ployed. When  the  venous  congestion  is  relieved  in  this  Avay  the  arterial 
blood  circulates  through  the  capillaries  much  more  readily,  and  the  cir- 
culation is  restored  much  more  rapidly  than  when  the  venous  blood  is 
allowed  to  stagnate  preventing  free  capillary  circulation.  Clinical  ex- 
perience has  repeatedly  demonstrated  the  value  of  early  suspension  in 
the  treatment  of  frozen  extremities.  Ritter's  view  that  venous  conges- 
tion has  a  favorable  influence  upon  the  regeneration  of  tissue  does  not 
seem  to  hold  good  in  these  cases.  Venous  congestion,  however,  even  when 
artificially  induced,  is  of  no  value  when  stasis  with  threatened  gangrene 
is  already  present. 

Undoubtedly  the  artificially  induced  arterial  hyperamiia  advised  by 
Ritter  is  of  value  in  the  treatment  of  long  persisting  (edema  and  cya- 
nosis. The  hot-air  cabinets  of  Bier  and  Krause,  in  which  the  limb  is 
allowed  to  remain  for  one  hour,  warm  baths  combined  with  cold  douches, 
friction  obtained  by  rubbing,  and  alcohol  compresses  are  of  value  in 
the  treatment  of  these  chronic  changes.  The  same  procedures  are  to  be 
employed  in  the  treatment  of  the  paralyses,  the  muscular  contractions, 
and  the  circulatory  disturbances  resulting  from  changes  in  the  vessels. 

The  frozen  part  should  always  be  sterilized  and  dressed  aseptically 
in  order  to  prevent  infection.  Ruptured  vesicles  and  loosened  shreds 
of  epidermis  should  be  removed,  preventing  in  this  way  the  retention 
of  bacteria.  Ulcers  and  denuded  areas  should  be  dressed  with  salve 
(zinc  oxid  ointment)  to  prevent  the  dressings  from  becoming  attached. 
The  dressing  should  be  changed  frecpiently,  as  the  profuse  secretion 
which  is  discharged  from  the  ulcers  and  gangrenous  areas  collects  be- 
neath them. 


620  THERMAL   INJURIES 

The  same  principles  should  be  followed  in  the  treatment  of  the  phleg- 
mons and  gangrene  as  have  already  been  described  in  the  chapters 
devoted  to  the  subjects.  Amputation,  which  should  be  made  in  healthy 
tissues,  should  be  delayed  until  a  distinct  line  of  demarcation  has  formed, 
unless  there  is  a  positive  indication  for  earlier  operative  interference. 
In  dry  gangrene  of  the  fingers  and  toes  and  some  of  the  other  parts, 
the  gangrenous  area  should  be  allowed  to  separate  spontaneously.  It 
may  be  necessary  to  perform  later  operation  to  improve  the  results  when 
the  gangrenous  parts  are  allowed  to  separate  spontaneously. 

It  is  often  difficult  to  treat  successfully  the  red  or  bluish  red  dis- 
coloration of  the  nose  which  frequently  persists  after  milder  degrees 
of  freezing  of  this  organ.  Riedinger  has  recommended  injections  of 
ergotin  in  these  cases.  Repeated  needling  and  injections  of  small 
amounts  of  alcohol  may  be  tried. 

Chilblains. — Chilblains  (perniones)  are  chronic  inflammatory,  usually 
circumscribed,  swellings  of  the  skin  which  follow  a  paralysis  of  the 
vessels,  serous  infiltration,  and  inflammatory  proliferation  of  the  skin 
and  subcutaneous  tissues.  They  occur  most  frequently  upon  the  hands 
and  feet  (especially  upon  the  extensor  surfaces,  on  the  outer  margins 
of  the  foot,  and  about  the  heel),  more  rarely  upon  the  face,  occasion- 
ally upon  the  penis.  Chilblains  are  caused  by  repeated  frostbites,  espe- 
cially those  following  the  wearing  of  wet  footwear  in  cold  weather  and 
standing  for  a  long  time  in  cold  water.  They  are  most  common  in 
anaemic  individuals,  especially  in  chlorotic  girls. 

Chilblains  develop  as  painful,  itching  nodules  which  are  bluish  in 
color  and  have  glistening  surfaces.  They  disappear  in  summer  to  recur 
in  the  winter,  persisting  until  the  chlorosis,  M^hich  may  be  a  contributing 
cause,  is  cured  or  the  occupation  is  changed. 

Vesicles,  pustules,  and  epithelial  defects  may  develop  as  the  result 
of  mechanical  influences  (rubbing,  pressure  of  a  shoe  or  boot,  scratch- 
ing). These  may  become  transformed  into  painful  ulcers  or  deep  rhag- 
ades,  and  may  be  followed  by  suppuration  of  the  chilblain.  The  cica- 
tricial contraction  following  these  lesions  may  cause  a  deformity. 

In  the  treatment  of  chilblains  an  attempt  should  be  made  to  stimu- 
late the  circulation  of  the  part  involved.  Warm  baths,  alcohol  com- 
presses, painting  with  tincture  of  iodin,  mildly  stimulating  salves  con- 
taining mercury  or  silver  nitrate,  and  the  hot-air  apparatus  are  of  value. 
The  affected  parts  must  be  protected  from  infection  by  cleanliness  and 
the  use  of  antiseptic  dressings  (zinc  oxid  ointment  dressing  maintained 
in  position  by  adhesive  plaster).  The  dressing  which  is  applied  should 
also  protect  the  chil])lnin  fi-oin  pressiu'c,  rubbing,  and  scratching.  One 
may  prevent  the  development  of  chilblains  by  weai-ing  warm  clothing, 
by  avoiding  tight  shoes  and  gloves,  by  wearing  overshoes,  by  carefully 


BURNS  621 

drying  the  foot  after  washing  or  when  they  become  wet,  and  by  improv- 
ing the  general  condition. 

Literature. — Giese.  Experiiiientelle  Untersuchuiigen  iibcr  iM-fricrungen.  Ilabilita- 
tionsschrift.  Jena,  1901. — Riedinger.  Ergotin  gegen  erfrorene  Xaseri.  Arch.  f.  klin. 
Chir.,  Bd.  20,  p.  457. — Ritter.  Die  Behandlung  dor  Krfriorungen.  Deutsche  Zeitschr. 
f.  Chir.,  Bd.  58,  p.  172. — Sonnenhunj.  Verbrenmingen  und  Erfiiorungcn.  Deutsche 
Chir.,  1879. 


CmVPTER    II 

BURNS 

High  degrees  of  heat  acting  upon  the  surface  of  the  body  produce 
pathological  changes  which  are  called  burns. 

Different  Causes  of  Burns. — Burns  may  be  caused  by  radiating  heat 
(sun  rays,  open  fires),  by  flames,  by  red-hot  metal  and  heated  solid 
bodies,  by  boiling  water  and  hot  li(iuids,  by  hot  steam  and  gases  (espe- 
cially steam  liberated  from  bursting  boilers  and  gases  generated  in 
the  explosion  of  powder,  dynamite,  and  coal  damp).  The  pathological 
changes  caused  by  caustics  are  similar  to  those  of  the  mildest  burns. 

Different  Degrees  of  Burns, — The  diflPerent  forms  of  heat  do  not  have 
the  same  action;  for  example,  radiating  heat  never  causes  more  than 
vesicle  formation,  while  direct  contact  with  a  red-hot  solid  body  is 
almost  always  followed  by  eschar  formation.  The  results  depend  upon 
the  time  the  heat  acts  and  upon  its  proximity  to  the  part  Involved. 
Three  different  degrees  of  burns  are  recognized.  The  first-degree  burn 
is  characterized  by  hypera^mia  or  erythema,  the  second  by  the  formation 
of  vesicles,  the  third  by  eschar  formation.  The  three  degrees  are  often 
associated.  A  fourth  degree,  characterized  by  charring  and  disorgani- 
zation of  the  burned  part,  is  sometimes  recognized. 

Burns  of  the  First  Degree. — The  first-degree  burn  (combustio 
erythematosa)  is  characterized  by  a  reddening  of  the  skin,  which  is 
caused  by  a  dilatation  of  the  cutaneous  vessels.  The  redness  is  accom- 
panied by  pain,  which  increases  for  a  few  hours  and  then  gradually 
subsides,  and  by  some  swelling  which  imparts  to  the  affected  part  a 
sensation  of  tenseness.  Sunburn  (erythema  solare)  is  the  most  common 
and  best  example  of  a  burn  of  the  first  degree.  The  first-degree  burn  is 
always  present  in  the  severer  burns.  It  is  much  more  easily  produced 
in  children  than  in  adults. 

The  redness  disappears  in  about  two  days.  It  is  followed  by  a 
broM^nish  discoloration  which  in  tui'n  disappears,  when  in  about  five 
days  the  fissured  horny  layer  of  the  epidermis  is  cast  oft'  in  shining 
scales. 


622  THEKMAL   INJURIES 

If  the  areas  deprived  of  their  horny  layer  are  then  again  exposed 
to  radiating  heat,  a  second-degree  burn  characteri/.ed  by  tlie  formation 
ot  vesicles  is  produced,  for  the  areas  are  very  sensitive.  The  formation 
of  vesicles  is  then  followed  by  the  development  of  scaling  crusts  (eczema 
solare).  Sunburn  is  frequently  followed  by  pigmentation  of  the  skin, 
causing  the  brownish  discoloration  so  well  known  to  all. 

The  burning  pain  associated  with  burns  of  the  first  degree  is  usually 
readily  relieved  by  the  application  of  an  ointment  (lanolin,  vaseline, 
zinc  oxid).  These  ointments,  applied  before  exposure  to  heat,  will  pre- 
vent the  development  of  a  burn  of  the  first  degree. 

Burns  of  the  Second  Degree. — A  burn  of  the  second  degree  (com- 
bustio  bullosa)  is  characterized  by  the  formation  of  vesicles  within  the 
reddened  and  swollen  cutaneous  area.  The  vesicles,  varying  in  size, 
which  develop  within  a  few  hours  or  after  a  number  of  days  contain 
a  clear  serous  or  light  yellowish  turbid  fluid  or  a  clotted  gelatinlike 
mass.  \¥hen  the  vesicle  bursts  or  the  cuticle  is  removed,  the  cutis  vera, 
red  and  painful,  is  exposed.  These  areas,  unless  protected,  afford  infec- 
tion atria  for  mild  and  severe  infections. 

The  contents  of  the  vesicles  may  be  absorbed,  and  then  they  later 
collapse  and  become  replaced  by  a  thin  crust.  If  infection  does  not 
occur  the  crust  drops  off  in  a  w^eek,  a  new  epithelium  having  developed 
beneath  it  from  the  stratum  IMalpighii.  In  a  short  time  a  slight  redden- 
ing is  the  only  evidence  which  remains  to  indicate  the  location  and 
extent  of  the  burn.  A  large  flat  scar  remains  after  a  burn  of  the  second 
degree  only  Avhen  the  corium  has  suppurated. 

That  severe  pain  is  associated  with  burns  of  the  second  degree  is 
well  known  to  everyone.  The  pain  gradually  subsides  on  the  third  or 
fourth  day,  wdien  the  swelling  and  redness  disappear. 

The  most  common  and  purest  type  of  a  burn  of  the  second  degree 
is  one  caused  by  scalding  with  hot  liquids  or  steam  or  by  contact  with 
a  naked  flame. 

The  indicati(ms  in  the  treatment  of  a  burn  of  the  second  degree  are 
to  relieve  the  pain,  and  to  provide  conditions  which  will  favor  rapid 
healing.  Pain  should  be  relieved  by  the  application  of  a  well-fitting 
protective  dressing;  if  necessary,  by  morphin.  Healing  is  more  rapid 
when  a  dry  dressing  is  employed,  provided  there  is  no  suppuration,  than 
when  ointments,  moist  dressings,  or  continuous  baths  (which  macerate 
the  tissues  and  provide  new  infection  atria)  are  used. 

Since  thorough  sterilization  is  impossible  because  of  the  pain  and  the 
danger  of  rupturing  the  vesicles,  the  grosser  particles  of  dirt  should 
be  removed  by  sponges  saturated  with  alcohol  or  a  three  per  cent  solu- 
tion of  hydrogen  peroxid. 

All  ruptui-<'d  vesicles  and  denuded  areas  should  be  regarded  as  in- 


BURNS 


623 


fected.  The  detached  shreds  and  strips  of  the  epidermis  should  be  re- 
moved with  scissors  and  forceps,  as  bacteria  become  lodged  within  and 
beneath  them.  Vesicles  which  have  not  been  ruptured  should  be  incised 
at  their  bases  with  a  sterile  knife,  for  when  they  collapse  the  epidermis 
forms  a  protecting  covering  to  the  underlying  tissues  to  Avhich  it  be- 
comes adherent.     Small  vesicles  should  not  be  opened. 

After  the  grosser  particles  of  foreign  matter  have  been  removed,  a 
dry  dressing  or  a  moist  dressing  saturated  wath  a  boric  acid  or  soda 
solution,  evaporation  from  which  should  not  be  prevented,  should  be 
applied.  The  lower  layers  of  such  a  dressing  become  attached  to  the 
denuded  area.  They  should  be  allowed  to  remain  until  separated  spon- 
taneously, unless  there  is  an  indication  for  earlier  removal.  The  dress- 
ing employed  by  Bardeleben,  consisting  of  gauze,  the  meshes  of  which 


Fig.  236.- 


-Hypertrophic  Scar  of  the  Forearm  and  Hand  following  a  J?urn 
Received  in  a  Theater  Fire. 


contain  equal  parts  of  powdered  starch  and  bismuth,  is  also  to  be  recom- 
mended. The  gauze  forms,  with  the  secretion  from  the  denuded  area, 
a  protecting  crust  beneath  which  healing  occurs  in  from  one  to  two 
weeks.  When  the  dressing  is  to  be  removed  the  crust  should  be  moist- 
ened with  vaseline  or  oil.  If  an  infection  occurs,  the  development  of 
which  is  indicated  by  fever  and  increasing  pain  in  the  wound,  the  dress- 
ings should  be  changed. 

Burns  of  the  Third  Degree. — The  third-degree  burn  ( combust io 
eseharotica)  is  characterized  by  the  formation  of  an  eschar.  The  tissues 
are  destroyed  to  various  depths  by  the  direct  action  of  the  heat  (most 
commonly  by  contact  Avith  red-hot  metal  or  flames),  and  a  hard,  insen- 
sitive, sometimes  yellow,  at  other  times  brown  or  black  mass,  the  vessels 
of  which  are  closed  by  thrombi,  forms.  This  mass,  like  any  other  form 
of  necrotic  tissue,  is  separated  fi'om  the  surrounding  parts  by  the  de- 


624 


THERMAL    INJURIES 


velopment  of  granulation  tissue.    The  eschar  following  freezing  develops 
slowly,  while  that  following  burns  develops  immediately. 

Burns  of  the  first  and  second  degree  are  usually  found  in  the  area 
surrounding  the  eschar.  During  the  separation  of  the  necrotic  mass 
mild  pyogenic  and  putrefactive  infections,  accompanied  by  local  and 
general  symptoms,  frequently  develop.  Occasionally  the  separation  of 
an  eschar  involving  deep  tissues  is  followed  by  the  opening  of  joints 
and  body  cavities,  the  erosion  of  large  blood  vessels,  thrombosis  and  em- 
bolism, and  the  devel- 
opment of  chronic  sup- 
puration ending  in 
amyloid  degeneration 
of   the   viscera. 

When  the  eschar  is 
cast  off  a  granulating 
wound,  which  is  in- 
clined to  form  exces- 
sive amounts  of  scar  tis- 
sue when  contraction 
occurs,  is  exposed.  The 
radiating,  red  and  hard, 
frequently  k  e  1  o  i  d  1  i  k  e 
scars  which  follow 
burns  are  to  be  feared, 
not  only  because  they 
are  disfiguring,  but  also 
because  they  frequently 
cause  adhesions  be- 
tween different  parts, 
thus  interfering  with 
the  functions  of  the 
same.  Scars  upon  the 
face  and  neck  produce 
frightful  disfigurement 
(ectropion  of  the  lids 
and  lips  and  cicatricial 
adhesions,  for  example, 
between  the  chin  and 
neck).  Developing  in 
llic  groin,  in  the  pop- 
lilcal  space  and  axillary  fossa,  about  flic  elbow,  and  upon  the  flexor  sur- 
face of  the  wtisj  joiiil,  lliey  may  cause  coiifj-act-ures.  The  arms  may 
liccoiiie  iiiiiiiovablv  allaclied  1o  the  thorax  when  a  burn  involviuij:  corre- 


/ 


/ 


I..  'J'.',7 .  Si  \  I,-  \  i  I  !,'  ■  ,  1,1  .  ,  I  li  I  (  ']l|\  \  \  11  (  'll  l:ST 
WHICH  FOLLOWED  THE  JIeALING  OF  A  WCALD  Pllf)I)UCED 
BY    HcJILINO    WA'IEII. 


BURNS 


625 


spending  surfaces  of  these  two  parts  cicatrizes  (Fig.  238).    If  traction  is 
continually  exerted  upon  a  scar,  fissures  develop  which  suppurate  and 


Fig.  238. — Cicatricial  Adhesions  hiiwkex  the  Ahm,  Thor.\x,  axd  Hack 
FOLLOWING  Scalding. 


lead  to  the  formation  of  chronic  ulcers.     Occasionally  a  carcinoma  de- 
velops Avithin  such  an  ulcer. 

The  treatment  is  the  same  as  described  -when  discussing  burns  of 
the  second  degree.  The  crust  formed  l)y  the  desiccation  of  the  secretion 
is  the  best  protection  against  putrefactive  infections.  The  area  may 
be  dressed  Avith  bismuth  powder  until  the  burns  of  the  second  degrees 
are  healed.     As  soon  as  the  granulation  tissue  begins  to  secrete  pro- 


626  THERMAL    INJUUIES 

fiisely,  dry  dressing  (which  should  be  changed  fre(inently)  should  be 
applied. 

In  extensive  burns,  after  separation  of  the  necrotic  tissue,  cleansing 
of  the  granulation  tissue  may  be  hastened  by  placing  the  patient  in  a 
warm-water  bath.  The  same  results  may  also  be  obtained  by  the  use 
of  ointments  and  moist  dressings.  If  the  granulating  wound  appears 
clean,  skin-gr;ifting  should  be  performed  at  once,  in  order  to  reduce  to 
a  minimum  the  amount  of  cicatricial  tissue.  If  the  scar  is  disfiguring 
or  interferes  with  function,  it  is  often  advisable  to  excise  it  and  to 
graft  the  resulting  wound.  If  the  sear  is  extensive,  it  may  be  neces- 
sary to  perform  a  number  of  operations,  or  mereJy  to  excise  the  part 
of  the  scar  which  causes  the  greatest  functional  disturbance.  An  at- 
tempt may  be  made  to  soften  the  scar  by  injecting  thiosinamin,  if  exci- 
sion is  not  desired  or  is  impossible. 

Secondary  phlegmons,  which  develop  most  connnonly  during  the  sep- 
aration of  the  eschar,  should  be  incised.  If  they  are  associated  with 
severe  general  infection,  amputation  should  be  considered. 

Carbonization. — Carbonization  is  observed  in  cadavers  found  after 
fires  and  mine  explosions.  Single  extremities  or  parts  of  the  same  may 
be  carbonized  when  molten  metal  is  poured  over  them.  An  imbecile  or 
insane  person  occasionally  holds  an  extremity  in  the  fire  until  carboni- 
zation occurs.  The  burned  part,  when  carbonized,  becomes  transformed 
into  a  charred,  brittle  mass  which  requires  amputation. 

General  Symptoms. — General  symptoms  are  wanting  if  the  area  af- 
fected is  small  and  there  is  no  infection.  If  the  temperature  is  carefully 
observed  it  will  often  be  found  that  a  general  reaction  accompanies  even 
the  milder  burns.  The  temperature  gradually  rises,  returning  to  normal 
in  about  twelve  days,  and  albumoses,  indicating  increased  destruction  of 
albumins,  appear  in  the  urine  (Wilms). 

If  more  than  one  half  of  the  surface  of  the  body  is  burned,  inde- 
pendent of  the  degree  of  the  burn,  severe  general  symptoms,  which 
almost  always  terminate  fatally  within  the  first  few  days,  may  develop. 
Any  burn  that  involves  one  third  of  the  surface  of  the  body  is  serious, 
and  is  apt  to  prove  fatal.  This  fact  was  first  emphasized  by  Billroth. 
Even  if  the  individual  withstands  the  innnediate  shock  of  an  extensive 
burn  and  the  general  sym{)toms  which  develop  during  the  first  few  days, 
he  may  die  later  of  infection  or  pneumonia. 

A  badly  burned  patient  is  at  first  conscious,  but  has  no  idea  of  the 
gravity  of  his  condition,  lie  is  restless,  throws  himself  about,  cries  out 
with  severe  p;iiii,  i)l('ii(ls  loi-  rclicl",  ;uid  ('oiii|)lains  of  great  thirst.  The 
unburjK'd  skin  is  while;  the  tciiipcratui-e  is  two  or  three  degrees  lower 
Ih.iii  noiiiinl.  Tliis  reduction  in  1emi)ei"ature  is  partly  due  to  the  rapid 
radiation  of  he;it  Ironi  the  (•;ij)in;iries  which  are  exposed  in  the  burned 


BURNS  627 

area,  and  partly  to  cardiac  weakness.  Vomiting,  occurring  soon  after 
the  burn  is  received,  is  a  bad  prognostic  sign.  In  tlie  severest  cases  the 
patient  becomes  apathetic  and  unconscious  in  a  few  hours;  the  pulse 
becomes  small  and  rapid;  the  respirations  very  rapid  and  superficial. 
Vomiting,  diarrhoea,  cyanosis,  delirium,  clonic  spasms,  coma,  and  col- 
lapse, which  are  more  pronounced  in  some  cases  than  in  others,  com- 
plete the  clinical  picture,  which  soon  ends  in  death.  The  urine  is 
scanty;  anuria  may  be  present.  Frequently  the  temperature  rises  rap- 
idly before  death.  Because  of  the  rapid  radiation  of  heat  from  the  skin, 
the  rectal  temperature  may  be  three  or  four  degrees  higher  than  the 
axillary  temperature. 

Pathological  Anatomy, — The  pathological  changes  found  by  post- 
mortem examination  are  so  slight  that  they  can  scarcely  account  for 
death.  Venous  congestion  of  the  viscera  and  of  the  cranial  sinuses; 
slight  oedema  of  the  brain  and  its  membranes ;  ecchymoses  of  the  mucous 
membrane  of  the  gastrointestinal  tract,  of  the  muscles,  and  of  the  serous 
membranes;  rarely  duodenal  ulcers  following  thrombosis  and  subseciuent 
digestion  of  the  necrotic  area,  and  often  slight  parenchymatous  degen- 
eration of  the  kidneys  are  found. 

Causes  of  Death. — Opinions  differ  widely  concerning  the  cause  of 
death  following  bui-ns  when  it  is  not  due  to  secondary  diseases  and  in- 
fection. Sonnenburg  believes  that  death  following  immediately  the 
reception  of  a  severe  burn  is  due  to  overheating  of  the  blood.  In  other 
cases  death  is  due  apparently  to  a  combination  of  different  causes.  In 
some  cases  death  is  probably  due  to  the  destruction  of  red  corpuscles, 
and  the  injury  done  the  kidneys  by  the  excretion  of  degeneration  prod- 
ucts; in  other  cases  to  the  shock  following  a  reflex  loss  of  vascular  tone 
and  secondary  cardiac '  paralysis ;  and  in  still  other  cases  to  extensive 
capillary  thrombosis  following  the  degeneration  of  blood  corpuscles. 
Recent  investigators  lay  more  stress  upon  the  diminution  in  the  amount 
of  blood  plasma  as  the  cause  of  death,  especially  in  burns  of  the  second 
degree  (Wilms),  and  upon  the  absorption  of  toxic  substances  from  the 
burned  area,  especially  in  burns  of  the  third  degree.  These  toxic  sub- 
stances, when  absorbed,  probably  interfere  with  the  metabolism  of  albu- 
mins (Wilms)  and  cause  degeneration  and  inflammatory  changes  in  the 
viscera,  especially  in  the  brain  (Dohrn).  It  has  not  been  possible,  how- 
ever, to  demonstrate  toxic  substances  in  the  burned  tissues  (Helsted) 
or  in  the  blood  (Burkhardt).  Therefore  the  solution  of  the  red  cor- 
puscles is  not  to  be  regarded  as  due  to  toxins,  but  the  result  of  the  direct 
action  of  the  heat  (Burkhardt,  H.  Pfeiffer,  Plelsted). 

Indications  for  Treatment. — The  indications  in  the  treatment  of 
severe  burns  are:  (1)  To  control  pain;  (2)  to  combat  shock;  (3)  to 
restore  the  fluids  which  are  being  lost  by  the  extravasation  of  serum; 


62S  THERMAL   INJURIES 

(4)  to  aid  in  the  elimination  of  toxic  materials  from  the  body;  (5)  to 
prevent  infection.  If  collapse  is  threatened,  subcutaneous  or  intra- 
venous injections  of  salt  solution  should  be  given.  The  loss  of  heat  fol- 
lowing the  destruction  of  large  areas  of  skin  is  often  followed  by  col- 
lapse. It  should  be  counteracted  by  placing  the  patient  in  a  warm  bed 
and  enveloping  the  uninjured  parts  of  the  body  in  cotton  and  warm 
cloths.  It  is  often  advisable  to  float  the  patient  in  a  bathtub  filled  with 
warm  water. 

X-ray  Burns. — X-ray  burns,  resulting  from  too  close,  too  long,  and 
too  frequent  exposures,  are  divided  into  the  acute  and  chronic.  They 
do  not  appear  immediately  after  exposures,  but  become  evident  some- 
what suddenly  after  a  week.  In  the  mild  cases  there  may  have  been 
no  premonitory  symptoms  after  the  exposure,  except  a  slight  transitory 
redness. 

In  the  acute  cases  the  pathological  changes  correspond  to  those 
already  described  in  discussing  burns.  The  mild  burns  are  character- 
ized by  erythema,  the  severe  ones  by  the  formation  of  vesicles,  the 
severest  by  the  destruction  of  tissue.  When  the  eschar  is  cast  off,  the 
painful  X-ray  ulcer  remains.  The  mildest  changes  consist  of  a  falling 
out  of  the  hair  in  the  area  exposed  to  the  rays.  All  these  changes 
gradually  disappear  within  a  number  of  weeks.  The  hair  grows  again 
after  six  or  eight  Aveeks  and  the  ulcers  heal.  The  skin  in  which  vesicles 
have  formed  frequently  remains  atrophic. 

The  chronic  lesions  which  not  infrequently  develop,  even  when  the 
exposures  are  made  by  skilled  physicians  and  technicians,  consist  of 
atrophy  of  the  glands  of  the  skin  and  falling  out  of  the  hair,  of  atro- 
phy of  the  skin  with  abnormal  pigmentation  and  fissuring  of  the  nails, 
and  of  the  development  of  painful,  progressive,  chronic  ulcers.  Other 
changes  which  are  frequently  associated  with  an  obliterating  endarter- 
itis may  also  develop  (Miihsam). 

The  number  of  X-ray  burns  have  been  greatly  reduced  of  late  by 
carefully  regulating  the  time  of  exposure,  and  by  using  lead  plates  and 
other  devices  which  protect  the  parts. 

Similar  pathologiea]  chang(»s  iuive  been  observed  after  the  use  of 
radium  (Halkin). 

The  same  treatment  should  Ix'  e]iij)l()yed  for  these  lesions  as  already 
advised  in  discussing  burns. 

Lightning-stroke. — Lightning  may  lacerate  or  burn  the  part  which 
it  sti'ikcs.  Burns  produced  by  it  are  often  accompanied  by  severe  shock 
(Sonnenburg). 

The  shock  produced  by  a  lightning-strolce  is,  as  a  rule,  followed  by 
i)iimedi{it(;  dcatli  caused  by  a  paralysis  of  the  vasomotor  and  respiratory 
centers.     An  individual  who  is  not  killed  instantly  presents  the  symp- 


BURNS  629 

tonis  of  cerebral  concussion.  An  individual  who  has  suffered  a  light- 
ning-stroke becomes  unconscious  aud  motionless,  the  pulse  is  weak  and 
slow  or  cannot  be  felt,  the  respirations  are  superficial,  the  extremities 
are  paralyzed,  and  there  is  no  response  to  external  stimuli.  These  symp- 
toms may  subside  within  twenty-four  hours  or  more  slowly,  the  con- 
valescence extending  over  a  period  of  many  weeks.  Often  a  feeling  of 
anxiety  and  unrest  and  a  paralysis  of  some  of  the  muscles  remain.  As 
a  rule  these  disappear  completely,  but  it  may  be  a  long  time  before  the 
condition  of  the  })atient  may  be  regarded  as  normal.  People  surround- 
ing an  individual  who  is  struck  by  lightning  are  usually  stunned,  but 
the  effects  are  transitory  and  rapidly  disappear. 

The  lacerating  force  of  lightning  is  so  great  that  not  only  may  the 
clothing  be  torn  in  shreds,  but  an  entire  extremity  may  be  torn  from 
the  trunk.  Other  injuries  are  often  sustained,  as  the  individual  may  be 
forcibly  thrown  to  the  ground  or  hurled  some  distance  by  the  shock. 

Besides  burns  of  different  degrees,  there  are  also  found  the  points 
of  entrance  and  exit  of  the  lightning,  the  course  of  which  nuiy  be  traced 
in  the  skin  and  deeper  tissues.  Deep,  round  eschars,  which  correspond 
to  the  areas  burned  in  the  clothing,  are  often  found  in  the  skin.  Red- 
dish brown  streaks  with  vinelike  branches  and  markings  radiate  in 
various  directions  through  the  skin  from  the  point  of  entrance.  The 
so-called  "  lightning  figures  "  are  caused  by  burns  of  the  cutis,  by 
laceration  of  the  cutaneous  vessels,  and  coagulation  of  the  extravasated 
blood.  At  the  point  of  exit  of  the  lightning  the  skin  is  perforated  at 
a  number  of  points,  the  skin  surrounding  the  perforations  being  charred 
and  discolored.  Burns,  often  of  the  third  degree,  may  be  found  where 
the  clothing  is  applied  closely  to  the  body,  or  where  there  is  metal  (but- 
tons, coins,  spectacles),  which  is  melted  by  the  lightning. 

In  the  treatment  an  attempt  should  be  made  to  correct  the  cardiac 
and  respiratory  disturbances  by  cardiac  massage  and  artificial  respira- 
tion and  by  administering  cardiac  stinudants.  The  paralyses  which 
remain  after  recovery  should  be  treated  by  electricity  and  massage. 
The  burns  should  be  dressed  as  described  above. 

Sunstrokes  and  Heat  Strokes. — Sunstrokes  and  heat  strokes,  which 
not  infrecpiently  terminate  fatally,  are  usually  due  to  a  high  elevation  of 
body  temperature.  Sunstrokes  are  caused  by  the  direct  action  of  the 
sun's  rays  upon  the  body,  especially  upon  the  bare  head,  of  individuals 
who  Avork  or  sleep  in  the  sun.  The  prodromata,  consisting  of  severe 
headache,  dizziness,  ringing  in  the  ears,  and  spots  before  the  ej'es,  are 
rapidly  followed  by  unconsciousness  associated  with  convulsions.  The 
face  is  reddened  and  injected,  the  skin  hot,  the  pulse  rapid  and  weak. 
The  temperature  may  rise  to  109°  F.  oi'  higher.  Death  nuiy  occur  within 
a  few  hours  as  a  result  of  cardiac  paralysis,  the  patient  not  having  re- 


630  THERMAL    INJURIES 

gained  consciousness.  In  less  severe  cases  the  patient  may  gain  con- 
sciousness after  a  longer  or  shorter  period  and  recover  completely,  if 
the  body  temperature  is  reduced  by  sponging  or  by  an  ice-pack.  Post- 
mortem examination  reveals  in  these  cases  a  hyperffimia  of  the  mem- 
branes of  the  brain  and  a  cerebral  oedema. 

Heat  stroke  is  due  less  to  overheating  of  the  body  by  the  action  of 
external  heat  than  to  an  interference  Avith  the  radiation  and  conduction 
of  heat  produced  by  metabolism  and  muscular  activity.  In  the  tropics 
a  heat  stroke  may  be  caused  by  an  interference  in  the  loss  of  heat  alone, 
while  in  temperate  climes  there  is  also,  as  a  rule,  an  increased  formation 
of  heat  resulting  from  muscular  action  (Musehold). 

People  who  succumb  most  easily  and  frequently  to  heat  strokes  are 
those  who  are  compelled  to  perform  hard  physical  labor  in  humid 
weather,  and  who  wear  clothing  which  interferes  with  evaporation  from 
the  skin.  Heat  stroke  is  very  common  in  soldiers  when  marching  in 
closed  columns  in  hot  weather  and  in  alcoholics. 

Profuse  sweating,  weakness,  distress,  and  great  thirst  are  the  pro- 
dromata.  Severe  headache,  dizziness,  a  feeling  of  anxiety,  and  vomit- 
ing rapidly  follow.  The  speech  becomes  thick,  the  sight  dim,  the  patient 
holds  himself  erect  wdth  difficulty,  or  staggers  until  he  suddenly  falls, 
and  becomes  unconscious  and  motionless.  The  face  is  puffy  and  cya- 
notic; the  pulse  is  rapid  and  thready,  if  palpable.  The  heart-tones  are 
weak,  often  irregular;  the  breathing  is  superficial  and  rapid;  the  skin 
is  dry  and  hot;  the  clothing  is  wet;  the  temperature  is  104°  or  105°  F. ; 
the  reflexes  are  diminished  or  lost;  the  pupils  are  narrow  and  scarcely 
react.  Sometimes  general  clonic  spasms,  associated  with  rigidity  of  the 
muscles  of  mastication  and  of  the  back,  develop. 

A  majority  (sixty -six  per  cent)  of  the  severe  cases  die  within  a  few 
hours  of  cardiac  paralysis.  The  milder  cases  recover,  but  even  when 
convalescence  is  well  established,  disturbances  of  the  central  nervous 
system  (headache,  dizziness,  impaired  memory,  transitory  mental  con- 
fusion)  and  cardiac  weakness  remain. 

Post-mortem  examination  reveals  a  venous  congestion  similar  to  that 
which  occurs  in  asphyxia,  systolic  contraction  of  the  left  ventricle  and 
dilatation  and  filling  of  the  right,  indicating  cardiac  paralysis.  A  heat 
stroke  is  to  be  regarded  as  a  carbonic  acid  intoxication  due  to  exhaus- 
tion of  the  cardiac  and  respiratory  centers  following  excessive  physical 
effort  and  interference  with  the  mechanism  controlling  the  loss  of  heat. 

Treatment  demands,  as  in  sunstroke,  an  in)mediate  reduction  of  body 
temperature  and  stinuilation  of  the  heart.  Artificial  respiration  and 
cardiac  massage;  injections  of  camphorated  oil;  rubbing  of  the  skin; 
the  pouring  of  coUl  water  over  the  body  and  the- use  of  ice-packs ;  the 
administration  of  large   amounts  of  water,  or,  if  the  patient  cannot 


BURNS  631 

swjillow,    rectal    injection   of   physiological   salt   solntion,    are   of   great 
value. 

The  prodroniata  of  a  heat  stroke  are  best  treated  by  removing  the 
patient  to  a  cool,  shaded  spot,  by  loosening  the  clothing,  and  by  admin- 
istering large  quantities  of  water.  A  heat  stroke  may  be  avoided  by 
Avearing  proper  clothing,  by  drinking  freely  of  small  quantities  of  water, 
mild  tea  or  coffee,  and  by  the  avoidance  of  alcoholic  drinks. 

Literature.—!'.  Bardelehen.  Ueber  Behandlung  von  Verbrennungen.  Deutsche 
med.  Wochenschr.,  1892,  No.  23. — Burkhardt.  Ueber  Art  uiid  Ursache  der  nach 
ausgedehiiteu  Verbrennungen  auftretenden  hiimolytischen  Erscheinungen.  Arch. 
f.  klin.  Chir.,  Bd.  75,  1905,  p.  845. — -Dohrn.  Zur  pathologischen  Anatomie  des  Friihtodes 
nach  Hautverbrennungen.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  60,  1901. — Eyff.  Die 
Hypothesen  liber  den  Tod  durch  Verbrennen  und  Verbriihen  im  19.  Jahrhundert. 
Sammelreferat  (1835  bis  1900).  Zentralbl.  f.  d.  Grenzgeb.,  Bd.  4,  1901,  p.  428.— Halkin. 
Ueber  den  Einfluss  der  Becquerelstrahlen  auf  die  Haut.  Arch.  f.  Dermatol,  u.  Syphil., 
Bd.  65. — A.  Hiller.  Der  Hitzschlag  auf  Marschen.  Bibliothek  von  Coler-Schjerning, 
No.  14,  1902. — -Kienbock.  Zur  Pathologie  der  Hautveriinderungen  durch  Rontgen- 
bestrahlung  bei  Mensch  and  Tier.  Wien.  med.  Presse,  1901,  No.  18. — Musehold. 
Sonnenstich,  Hitzschlag.  In  Eulenburgs  Realenzyklopadie,  3.  Aufl.,  1899,  Bd.  22. — 
Miihsum.  Ueber  Dermatitis  der  Hand  nach  Rontgenbestrahlung.  Arch.  f.  khn.  Chir., 
Bd.  74,  1904. — Saccormghi.  Sulle  alterazioni  anatomo-patologiche  degli  organi  interni 
in  seguito  a  scottatura.  Lo  sperimentale,  1901,  Nos.  5-6  (Hildebrands  Jahresber.,  1901, 
p.  174). — Sonnenburg.  Verbrennungen  und  Erfrierungen.  Deutsche  Chir.,  1879. — 
Tschmarke.  Ueber  Verbrennungen.  Deutsche  Zeitschrift  f.  Chir.,  Bd.  45. — Wilms. 
Stutlien  zur  Pathologie  der  Verbrennungen.     Mitteil.  aus  d.  Grenzgeb.,  Bd.  8,  1901. 


IV.     GENERAL    RESULTS    OF    INJURIES 

CHAPTER    I 

COLLAPSE,    SYNCOPE,    SHOCK 

Collapse,  syncope,  arid  shock  will  be  considered  together,  as  they 
are  closely  allied  conditions.  They  follow  frequently,  although  not  ex- 
clusively, injuries  of  all  sorts,  and  are  characterized  by  a  sudden  depres- 
sion of  all  the  vital  forces,  which  may  be  transitory  ending  in  recovery 
or  may  be  fatal.  The  clinical  pictures  are  very  similar,  and  often  they 
are  due  to  common  causes,  and  therefore  it  may  be  readily  understood 
that  frequently  one  passes  into  the  other. 

Collapse.— The  most  prominent  symptoms  of  the  condition  known 
as  collapse  are  a  sudden  giving  way  of  the  strength  of  the  individual 
and  a  weakening  of  the  heart.  There  are  a  number  of  different  causes 
of  collapse,  such  as  severe  haemorrhage  occurring  in  accidents  or  oper- 
ations; injuries  of  the  heart,  overexertion  of  the  latter  in  valvular  dis- 
ease, myocarditis,  and  disease  of  the  cardiac  vessels,  and  w4ien  sudden 
demands  are  made  upon  it,  as  in  pulmonary  embolism,  when  one  of  the 
larger  branches  of  the  pulmonary  artery  is  occluded  and  the  part  of 
the  lung  supplied  by  it  is  thrown  out  of  action  ;  anannia  of  the  brain, 
due  to  embolism,  or  occurring  when  an  anannic  patient  or  one  recover- 
ing from  an  ana'sthetic  is  placed  in  an  upright  position ;  poisonings 
(with  snake  venom,  long-contiimed  ana'sthesia,  with  chemical  agents) 
and  bacterial  intoxications  in  which,  according  to  Romberg  and  others, 
a  central  paralysis  of  the  vessels  is  the  principal  cause  of  collapse. 

Symptoms. — The  symptoms  are  7)allor  or  cyanosis  of  the  face;  cold 
sweat;  cold,  usually  cyanotic,  extrenn'ties;  dilated  pupils;  small,  rapid, 
scarcely  palpable,  irregidar  pvdse;  mild  delirium;  superficial  breath- 
ing (either  rapid  or  slow)  :  after  a  short  time  a  clouded  mentality, 
or  just  before  death  loss  of  consciousness;  vomiting,  and  a  marked 
fall  of  temperature  (95°  to  96°  F.)  even  in  febrile  disease.  These 
symptoms  may  develop  in  rapid  succession,  death  occurring  quickly 
or  after  slight  temporary  improvement,  if  the  Iveart  action  cannot  be 
maiiilaiiicd. 

G32 


COLLAPSE,  SYNCOPE,  SHOCK  633 

Treatment. — If  collapse  occurs  the  patient  should  be  placed  in  the 
head-down  posture,  which  should  be  maintained.  Injections  of  cam- 
phorated oil  should  be  given  to  stimulate  the  heart.  A  hypodermic 
syringeful  of  this  oil  may  be  given  every  fifteen  minutes  vintil  the  con- 
dition is  relieved.  In  collapse  due  to  haemorrhage,  physiological  salt 
solution  should  be  given  subcutaneously  or  intravenously,  depending 
upon  the  urgency  of  the  case.  Saline  transfusions  are  also  very  valu- 
able in  collapse  associated  with  poisonings  and  general  infections.  Arti- 
ficial heat  should  be  supplied  by  wrapping  the  patient  in  warm  blankets 
or  by  placing  hot-water  bottles  about  him.  Whisky  may  be  adminis- 
tered by  mouth  if  the  patient  is  conscious  and  can  swallow,  or  may  be 
given  by  rectum  with  hot  coffee.  [Crile  has  made  some  important 
observations  on  resuscitation  when  collapse  from  any  cause  has  reached 
the  stage  of  suspended  animation:  that  is,  when  the  circulation  and 
respiration  have  ceased.  lie  describes  the  method  in  Keen's  "  System 
of  Surgery,"  Vol.  I,  p.  945,  as  follows:  "  The  patient  is  placed  in  the 
horizontal  or  head-down  position.  The  tongue  is  held  well  forward, 
and  rapid,  rhythmic  pressure  is  applied  upon  the  chest  over  the  heart, 
thereby  providing  sufficient  artificial  circulation  during  the  insertion 
of  the  infusion  •  canula  directed  toward  the  heart  into  the  peripheral 
artery  or  vein.  As  soon  as  the  salt  solution  begins  to  flow  into  the  ves- 
sel, thrust  a  needle  of  a  hypodermic  syringe  filled  with  adrenalin  chlorid 
(1:1,000)  through  the  rubber  tube  near  the  canula,  and  during  about 
one  minute  inject  from  10  to  30  minims.  In  suitable  cases  the  heart 
will  promptly  begin  vigorous  beating,  and  after  some  time  spontaneous 
respiration  will  be  established.  The  circulation  should  be  closely  ob- 
served, and  should  there  be  evidence  of  failure,  a  continuous  intra- 
venous infusion  of  a  1 :  20,000  solution  of  adrenalin  chlorid  in  normal 
solution  should  be  given  as  long  as  required,  at  the  rate  of  2  to  3  e.c.  per 
minute.  In  the  mean  time  the  extremities  and  the  abdomen  should  be 
firmly  bandaged  over  plain  cotton,  or  the  rubber  pneumatic  suit  should 
be  a])plifd."] 

Syncope. — Syncope  is  a  sudden,  usually  transitory,  loss  of  conscious- 
ness due  to  reflex  antemia  of  the  brain  caused  by  psychical  influences. 
It  occurs  most  frequently  in  nervous,  irritable  women  and  in  men 
addicted  to  alcohol.  The  sight  of  blood  or  surgical  instruments,  the 
change  of  dressings,  severe  fright,  or  the  view  of  an  injured  person 
may  be  the  cause  which  produces  the  reflex  paralysis  causing  the  anannia 
of  the  brain  and  the  symptoms  associated  with  it. 

Symptoms. — Cadaveric  paleness,  nausea,  cold  sweat,  dizziness,  and 
darkening  of  the  field  of  vision  are  the  prodromata  of  s^^lcope.     With 
fixed  stare  and  widely  dilated  pupils  the  patient  sinks,  having  lost  con- 
sciousness rapidly  and  completely,  and  remains  motionless  and  insensible. 
41 


634  GENERAL   RESULTS   OF   INJURIES 

The  pulse  is  rapid  and  small  but  regular,  the  respiration  slowed  and 
superficial.  As  a  rule,  the  symptoms  rapidly  disappear,  a  fatal  termina- 
tion being  extremely  rare.  Fatal  syncope  has  been  most  often  observed 
in  greatly  excited  patients  shortly  before  surgical  operations  or  during 
operations  undertaken  under  local  anaesthesia. 

Consciousness  usually  rapidly  returns  when  the  patient  is  placed  in 
a  head-down  position,  thus  counteracting  the  cerebral  anfemia,  and  when 
the  clothes  are  loosened.  The  horizontal  position  should  be  maintained 
for  some  time  after  the  patient  recovers,  and  small  amounts  of  whisky 
or  wine  may  be  given  to  advantage.  If  the  patient  remains  in  a  deep 
faint  for  some  time,  the  same  treatment  as  described  under  collapse 
should  be  instituted. 

Shock. — Shock  is  a  condition  closely  related  to  collapse  in  which 
there  is  a  reflex  depression  of  all  the  vital  forces. 

Theories  of  Shock. — According  to  many  authors  (von  Leyden, 
Groningen,  and  others),  shock  is  due  to  an  exhaustion  or  inhibition  of 
the  centers  in  the  medulla  and  spinal  cord  following  excessive  irritation 
transmitted  from  the  periphery.  This  inhibition  or  exhaustion  of  the 
centers  is  followed  by  a  depression  of  the  functions  of  the  heart  and 
lungs,  the  vasomotor,  sensorj^,  and  motor  nerves.  Schiefter,  as  the  result 
of  animal  experimentation,  supports  this  theory,  for  he  found  that  shock 
was  much  less  easily  produced  in  animals  in  which  spinal  angesthesia 
had  been  induced  than  in  noi-mal  ones.  According  to  others,  especially 
H.  Fischer,  a  reflex  vasomotor  paralysis  is  the  cause  of  shock.  As  a 
result  of  this  vasomotor  paralysis,  just  as  in  Goltz's  tapping  experi- 
ments, the  veins  of  the  splanchnic  area  become  filled  with  blood  and  the 
blood  pressure  sinks  so  low  that  an  anannia  of  the  nervous  system 
develops.  Finally,  as  a  result  of  these  circulatory  disturbances  the 
heart  ceases  to  beat.  Irritation  of  the  sensory,  splanchnic,  and  other 
sympathetic  nerves,  and  of  the  branches  of  the  vagus  also  plays  a  role 
in  the  cardiac  inhibition,  for  a  transitory  inhibition  of  the  heart  can  be 
caused  by  stimulation  of  the  sensory  nerves  supplying  the  abdominal 
viscera. 

Shock  may  be  caused  by  the  concussion  or  contusion  of  areas  abun- 
dantly su])plied  l)y  sensory  nerves,  as  in  severe  injuries,  or  by  the  injury 
of  a  si)ecial  group  of  nerves.  Shock  follows  not  only  machine  injuries 
and  gunshot  wounds  of  the  trunk  or  extremities,  extensive  freezing  and 
])ui-iis,  but  also  contusions  of  the  tliorax,  in  which  the  branches  of  the 
vagus  nerve  are  stinnilated,  and  subcutaneous  injuries  of  the  abdomen, 
in  which  the  nerves  supplying  the  peritoneum  are  irritated  by  the 
trauma  or  by  the  contents  of  the  stomach  or  intestine  when  the  latter 
arc  ruptured.  Irritation  of  the  nerves  caused' by  packing  aside  and 
liiiiidliiig  the  intestines  in  laparotomies,  and  by  excessive  traction  upon 


COLLAPSE,  SYNCOPE,  SHOCK  635 

the  spermatic  cord  during  the  freeing  of  a  hernial  sac  may  cause 
shock. 

Age,  general  weakness,  cachexia,  and  aua?mia  caused  by  htemorrhage 
or  disease  are  predisposing  causes. 

Si/mptoms. — The  symptoms  of  shock  are  rapid  loss  of  strength;  de- 
pression of  cardiac  activity,  usually  associated  with  a  reduction  of  body 
temperature;  irregular  respiration  and  interference  with  the  spinal 
functions  as  indicated  by  relaxation  of  the  muscles,  diminution  or  loss 
of  reflexes  and  impairment  of  sensation,  consciousness  being  retained 
(Samuel).  In  the  milder  forms  of  shock  the  skin  is  pale  and  cold,  the 
patient  is  apathetic  or  restless,  movements  and  reflexes  are  sluggish,  the 
pulse  is  small  and  running  rather  than  slow,  and  the  respirations  are 
slowed.  In  the  severer  forms  the  skin  has  a  cadaveric  pallor  and  is 
cold;  the  lips  and  cheeks  are  cyanotic,  due  to  the  accumulation  of  blood 
in  the  veins;  cold  sweat  covers  the  body;  the  pupils  are  dilated  and 
react  sluggishly,  and  the  patient  has  a  fixed  stare;  he  may  belch,  hic- 
cough, or  vomit;  the  pulse  is  slow  or  but  slightly  faster  than  normal, 
and  is  scarcely  palpable ;  the  respirations  are  superficial  and  slow,  inter- 
rupted by  deep  inspirations;  the  body  temperature  is  lowered;  the 
acuity  of  perception  is  reduced;  the  reflexes  are  sluggish;  and  the 
fa?ces  and  urine  are  discharged  involuntarily.  The  mind  is  always 
clear,  but  cerebration  may  be  somewhat  slow  as  the  result  of  the  cerebral 
anaemia. 

Torpid  and  Erethistic  Shock. — The  condition  of  apathy  in  which  the 
patient  lies  prostrate  and  perfectly  relaxed  may  be  followed  by  a  stage 
of  excitement  or  anxiety  in  M'hich  the  limbs  are  tossed  about  and  the 
patient  rolls  about  in  bed,  attempting  to  rise.  Therefore  a  torpid  shock 
is  differentiated  from  an  erethistic  shock.  During  the  stage  of  excite- 
ment the  pulse  becomes  small  and  rapid,  the  respiration  very  rapid, 
and  the  face  reddened.  Frequently  torpid  passes  into  erethistic  shock; 
at  times  merely  transitory  periods  of  restlessness  occur. 

Psychical  Shock. — A  condition  which  is  caused  by  some  psychical 
excitement,  the  symptoms  of  which  are  usually  transitory  but  may  ter- 
minate fatally  as  a  result  of  inhibition  of  the  heart  is  called  psychical 
shock.  This  form  is  most  often  produced  by  sudden  fright,  the  sudden 
announcement  of  good  or  bad  news,  by  unexpected  noises  (e.  g.,  when 
a  gun  is  fired  near  by  without  warning) .  In  psychical  shock  conscious- 
ness is  retained,  differing  in  this  way  from  syncope. 

Shock,  even  in  mild  cases,  not  infrequently  terminates  fatally.  The 
fatal  termination,  as  a  rule,  is  not  due  to  the  interference  with  the 
function  of  the  central  nervous  system  alone,  but  is  due  especially  to 
the  loss  of  blood.  If  the  patient  is  going  to  recover  the  symptoms 
generally  subside  within  a  few  hours. 


636  GENERAL   RESULTS   OF    INJURIES 

Nothing  is  more  difficult  than  to  determine  when  the  symptoms  of 
shock  are  subsiding  in  a  patient  severely  injured,  especially  if  the  symp- 
toms of  shock  are  combined,  as  is  often  the  case,  with  those  of  internal 
haemorrhage  or  beginning  inflammation  (e.  g.,  peritonitis).  A  rise  of 
temperature  is  generally  associated  with  infections,  and  the  puLse,  which 
was  slow  or  normal,  becomes  rapid  in  both  ha-morrhage  and  infection. 
Severe  collapse  resembles  shock  very  closely,  and  if  it  develops  immedi- 
ately after  an  injury  it  can  hardly  be  differentiated  from  shock.  The 
differentiation  is  more  easily  made  when  there  is  some  cause  for  the 
collapse,  such  as  pulmonary  embolism,  febrile  disease,  etc. 

Pathologic  Physiology  of  SJtock. — The  experimental  work  done  by 
Crile  has  given  us  a  very  clear  idea  of  the  pathologic  physiology  of  shock, 
and  also  the  methods  of  preventing  and  treating  shock.  [In  Keen's 
' '  Surgery, ' '  Vol.  I,  p.  926,  he  writes :  ' '  An  abnormally  low  blood  pres- 
sure is  the  essential  phenomenon  of  the  state  commonly  designated  sur- 
gical shock.  There  are  many  other  physiologic  changes  accompanying 
shock,  but  these  may  for  practical  purjioses  be  regarded  either  as 
results  of  low  blood  pressure  or  as  factors  of  minor  importance.  Among 
these  secondary  factors  or  results  are  alteration  in  respiration  and  car- 
diac action,  modified  mental  state,  loss  of  power  of  both  the  voluntary 
and  involuntary  muscular  systems,  diminution  of  the  secretion  of  urine, 
and  lowering  of  body  temperature.  So  long  as  blood  pressure  and  cir- 
culation are  sufficient  for  normal  physiologic  purposes,  a  serious  state 
of  shock,  despite  the  presence  of  any  other  phenomena,  cannot  be  pre- 
sumed. As  IMummery  has  pointed  out,  the  fall  in  temperature  in  shock 
is  largely  a  result  and  not  the  cause  of  the  low  blood  pressure.  The 
exact  physical  state  of  the  vasomotor  center  during  the  existence  of 
shock  has  not  as  yet  been  satisfactorily  demonstrated.  The  result  of 
that  physical  state  is  an  inactivity  of  the  center  or  centers,  thus  causing 
a  k)w  blood  pressure.  But  it  is  not  certain  that  we  can  at  present  state 
just  what  exhaustion  or  j^aralysis  is.  In  a  certain  sense  the  vasomotor 
center  in  a  state  of  shock  may  be  d<^signated  as  paralyzed,  or  in  a  cer- 
tain other  sense  as  exhausted.  "We  do  know,  however,  that  whatever  the 
exact  physical  state  is,  one  may  conclude  from  the  phj^siologic  test  of 
complete  recovery  that  the  centers  ai-e  not  physically  damaged,  that  the 
impairment  or  breakdown  is  functi(»iud  and  temporary.  It  is  at  once 
apparent  that  in  the  management  of  operations  prevention  is  more  im- 
j)(>rtant  than  treatment."] 

I 'I' he  accompanying  bl()od-pressur(>  tracing  indicates  the  sudden  fall 
ill  blood  pressure  obtained  by  irritation  of  the  inflamed  pleura  by  a 
Iroeiir.  The  sudden  deaths  associated  witli  aspii-ation,  which  are  not 
iiirre(|iieiit,  are  apparently  due  to  shock  induced  by  stimulation  of  the 
lilaiiieiits  of  the  pneumogastric  and  sympathetic  nerves  supplying  the 


COLLAPSE,  SYNCOPE,  SHOCK 


637 


pleura,  leading  to  a  reflex  paralysis  of  the  vasomotor  centers  iu  the 
medulla  ()I)lon«>ata  and  spinal  eord  (Capps  and  Lewis).  | 

Prognosis. — A  marked  lowering  of  the  temperature  and  a  continued 
depression  of  cardiac  function,  even  Avhen  powerful  cardiac  stimulants 
are  administered,  are  bad  prog- 
nostic signs. 

Treatment.  —  The  indications 
in  the  treatment  of  shock  are  to 
prevent  further  irritation,  espe- 
cially pain,  and  to  improve  the 
cardiac  function  and  circulation. 
Painful  manipulation  should 
therefore  not  be  attempted,  and 
friction  of  the  skin  and  the  appli- 
cation of  mustard  plasters  are  to 
be  avoided.  Just  as  in  collapse, 
attempts  should  be  made  to  aid 
the  circulation  by  placing  the  pa- 
tient in  the  head-down  position, 
to  stimulate  the  heart  by  injec- 
tions of  camphorated  oil  and  heart 
massage,  to  aid  breathing  by  arti- 
ficial respirations,  and  to  supply 
heat  by  hot-water  bottles  or  bags. 
Whisky  in  hot  coffee  and  hot  ex- 
tract of  beef  given  by  mouth  or 
rectum  have  a  favorable  influ- 
ence. 

If  erethistic  shock  has  de- 
veloped, the  patient  should  be 
quieted  by  a  hypnotic,  preferably 
by  morphin.  As  these  cases  are 
apt  to  be  accompanied  by  fever, 
there  is  no  necessity  of  supplying 
external  heat. 

[Crile  summarizes  the  treat- 
ment that  should  be  employed  in 

shock    as    follows:    "Physiologic  ^^^  t '^ 

rest  is  the  most  important  con- 
sideration in  the  treatment  of  shock.  The  patient  should  be  kept  at 
rest  mentally  and  physically.  Surgeons  and  nurses  should  bring  assur- 
ance and  confidence.  The  patient  should  be  made  comfortable.  If 
this  cannot  be  satisfactorily   accomplished   by   management    and   nurs- 


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638  GENERAL  RESULTS  OF   INJURIES 

ing,  then  give  a  minimum  of  anodynes.  It  is  not  well  to  tax  the 
patient  with  unimportant  annoying  routine  measures.  The  foot  of 
the  bed  should  be  elevated.  In  more  critical  cases  the  extremities 
and  the  abdomen  may  be  snugly  bandaged.  Saline  solution  per  rec- 
tum, subcutaneously  or  intravenously,  according  to  the  urgency,  may 
be  given. 

"  If  the  foregoing  seems  unavailing,  15  minims  of  adrenalin  chlorid 
(1:1,000)  may  be  added  to  500  c.c.  saline  solution,  which  is  admin- 
istered subcutaneously,  and  in  extreme  urgency  a  continuous  infusion 
of  1 :  20,000  adrenalin  solution  at  the  rate  of  2  c.c.  per  minute  should  be 
tried."] 

Anjesthesia  and  any  operative  procedure  are  to  be  postponed  if  the 
patient  does  not  react  to  the  treatment  above  outlined.  Life-saving 
operations,  such  as  ligation  of  large  vessels,  laparotomies,  and  trache- 
otomies must  be  performed  even  when  there  is  shock. 

Literature. — H.  Fischer.  Ueber  den  Shock,  v.  Volkmanns  Samml.  klin.  Vortr., 
No.  10,  1870. — Groningen.  Ueber  den  Shock.  ^^'  esbaden,  1885. — Georg  Hirsch. 
Ueber  den  Shock.  I.-D.  Halle,  1901.^ — Krehl.  Patholog.  Physiologie.  Leipzig, 
1904. — De  Quervain.  Shock.  Kochers  chir.  Enzyklopadie,  1903. — Samuel.  Shock. 
Eulenburgs  Realenzyklopadie,  1889,  Bd.  18. 


CHAPTER    II 

DELIRIUM    TREMENS 

Delirium  tremens  develops  not  infrequently  in  drinkers,  most  com- 
monly in  whisky  drinkers,  less  often  in  wine  and  beer  drinkers,  after 
injuries,  especially  after  fractures  and  operations.  The  greatest  num- 
ber of  cases  naturally  occur  in  men,  as  they  are  more  often  addicted 
to  drink  than  women.  It  is  most  conunon  in  the  fourth  and  fifth 
deconnia. 

Prodromata  and  Symptoms. — Tlie  prodromata,  which  usually  develop 
on  the  day  following  the  injury,  consist  of  restlessness,  sleeplessness,  a 
fine  tremor  of  the  hands  and  tongue,  and  great  irritability.  The  patient 
talks  to  himself,  throws  himself  about  in  the  bed,  and  picks  at  his  dress- 
ings or  pulls  upon  the  restraining  bands  or  sheet.  After  a  few  hours 
hallucinations  develop,  and  he  sees  animals  of  all  kinds  in  the  room 
and  bed.  He  feels  them  upon  his  l)ody  and  attempts  to  pick  them  off 
and  drive  them  from  the  IxmI  and  room.  In  this  sleepless  condition  he 
is  still  more  disturbed  by  imagining  that  the  air  is  smoky  aiul  that  it  is 
choking  him,  that  the  room  is  a  prison  and  that  the  attendants  are 
guards.     The  condition   often   rapidly   becomes  worse,  and   the  patient 


DELIRIUM   TREMENS  639 

becomes  violent  as  delusions  of  persecution  develop.  The  delirious 
patient  shouts  like  a  maniac,  pours  out  invective,  and  strikes  at  the 
attendants,  particularly  when  efforts  are  made  to  restrain  him  or  place 
him  in  bed.  There  is  no  sense  of  pain,  and  he  uses  an  injured  or 
operated  extremity  as  a  normal  one;  for  example,  he  may  walk  upon 
the  stump  of  a  recently  amputated  leg,  or  beat  upon  the  wall  or  bed 
with  a  severely  inflamed  arm. 

Cardiac  Weakness  Occurring  in  Delirium  Tremens. — The  greatest  dan- 
ger is  cardiac  wetikness.  During  the  stage  of  excitement  the  heart  may 
suddenly  become  weak  and  rapid  or  stop,  and  the  patient  passes  into 
collapse,  which  nuiy  end  fatally.  The  heart  muscle  in  nearly  all  these 
patients  has  undergone  fatty  changes  as  the  result  of  long-continued 
alcoholism,  and  when  extra  work  is  put  upon  it  during  the  stage  of 
excitement  it  becomes  rapidly  exhausted.  In  the  favorable  eases,  which 
are  the  most  connnon,  the  patient  falls  into  a  long,  deep  sleep,  after 
the  delirium  has  lasted  for  some  days.  When  he  awakes  his  mind  is 
clear  and  he  has  no  recollections  of  the  preceding  hallucinations.  In 
the  less  favorable  cases  the  symptoms  gradually  subside,  but  fatal  col- 
lapse may  occur  at  any  time  in  these  cases. 

The  milder  cases  take  an  unfavorable  turn  if  an  infection  or  pneu- 
monia develops  or  a  htemorrhage  occurs,  as  the  weakened  heart  is  then 
not  able  to  perform  the  extra  amount  of  work  demanded  of  it. 

Prophylaxis. — An  attempt  should  be  made  to  prevent  the  develop- 
ment of  delirium  in  patients  addicted  to  alcohol,  and  for  this  reason 
alcoholic  drinks  should  not  be  withdrawn  at  once,  but  during  the  first 
week  following  the  injury  or  operation  the  usual  amounts  of  whisky, 
cognac,  port  wine,  or  other  alcoholic  drinks  should  be  given.  Even  after 
the  development  of  the  prodromata  the  severer  stages  of  the  delirium 
can  often  be  prevented  if  some  alcoholic  drink  is  administered.  Ac- 
cording to  Bonhoetfer,  alcohol  should  be  completely  withdrawn  after 
the  symptoms  have  developed,  for  it  has  no  influence  upon  the  later 
course  of  the  disease. 

Essential  Cause. — Nothing  definite  is  known  concerning  the  essential 
cause  of  delirium  tremens.  According  to  later  investigations  trauma  is 
not  so  important  a  factor  as  the  exciting  cause  as  are  infections  (par- 
ticularly pneumonia)  and  diseases  of  the  respiratory  passages  (fat  em- 
bolism following  fractures).  The  sudden  withdrawal  of  alcohol  is 
regarded  by  some  as  an  important  factor,  but  others  attach  much  less 
significance  to  it. 

Treatment. — When  the  delirium  has  developed,  morpliin,  chloral,  and 
scopolamine  (gr.  y-ig-  subcutaneously)  .should  be  given  to  quiet  the 
patient.  Injections  of  camphorated  oil  (which  can  rareh^  be  dispensed 
with)  should  be  given  as  a  heart  stimulant.    The  patient  should  be  fed; 


640  GENERAL   RESULTS   OF   LNJURIES 

hot  milk,  to  which  are  added  a  few  drops  of  tincture  of  capsicum,  beiii^j;: 
most  often  given.  [It  is  absolutely  essential  that  the  patient  receive  suf- 
ficient nourishment.  It  has  been  suggested  by  some  that  the  delirium 
which  occurs  in  these  patients  is  closely  related  to  the  delirium  which 
develops  during  starvation.  Patients  suffering  with  delirium  tremens 
should  never  be  etherized  or  chloroformed,  as  these  two  drugs  have  the 
same  physiological  action  as  alcohol,  and  when  the  patient  recovers  from 
the  anjEsthesia  the  symptoms  are  often  aggravated.] 

A  large  dressing,  held  in  place  by  plaster  of  Paris,  should  be  applied 
to  protect  the  wound  or  wounds  from  injury  and  infection.  The  patient 
should  then  be  placed  in  a  specially  prepared  room  and  watched  by  one 
or  two  powerful  attendants.  A  restraining  jacket  is  required  only  in 
the  severest  cases. 

Literature. — Bonhoeffer.      Zur  Pathogenese  des  Delirium  tremens.     Berl.  klin. 
Wochenschr.,  1901,  p.  832. 


CHAPTER    III 

PAT   EMBOLISM 

After  many  injuries,  particularly  after  fractures,  fat  droplets  gain 
access  to  and  circulate  in  the  blood,  this  being  indicated  by  the  presence 
of  fat  droplets  in  the  urine. 

Symptoms. — Distinct  clinical  symptoms,  which  may  lead  to  death,  are 
rare.  The  symptoms  depend  upon  the  amount  of  fat  which  gains  access 
to  the  blood  and  upon  the  viscera  involved,  and  not  upon  the  extent 
of  the  injury,  for  a  simple  fracture  of  the  fibula,  malleoli,  or  patella 
may  be  folloM^ed  by  a  fatal  fat  embolism.  It  is  doubtful  whether  a 
fracture  (with  crushing  of  the  marrow)  or  the  crushing  of  the  pan- 
niculus  adiposus  is  absolutely  essential  for  the  development  of  fat  em- 
bolism, for  Kibbert  has  been  able  to  produce  fat  embolism  experiment- 
ally in  ra])bits  by  percussing  the  tibia,  not,  however,  by  fracturing  the 
bone.  He  has  come  to  the  conclusion  that  the  general  concussion  to 
which  the  bony  system  is  subjected  in  injuries,  and  particularly  in  frac- 
tures, is  the  cause  of  the  liberation  of  fat,  which  is  then  absorbed  by 
the  lymphatics  and  carried  into  the  blood.  ITe  does  not  believe  it  prob- 
able that  the  fat  is  absorbed  from  the  crushed  bone  marrow  at  the  seat 
of  fracture,  for  the  lileeding  veins  and  those  which  are  closed  by 
thrombi  are  not  able  to  absorb  the  fat.  Fat  embolism  has  also  been 
observed  after  the  forcible  correction  of  contractures  (Payr,  Ahrens, 
and  others). 


FAT   EMBOLISM  641 

Symptoms  develop  as  soon  as  a  large  amount  of  fat  reaches  the  vis- 
cera, for  the  fat  occludes  the  smaller  vessels  and  interferes  with  the 
function  of  the  viscera  involved.  The  fat  emboli  first  lodge  in  tlie 
lung  and  a  haemorrhagic  infarct  develops,  the  symptoms  of  which  are 
rapid  respiration,  dyspnoea,  pallor  followed  by  cyanosis,  failure  of  cir- 
culation, and  hemoptysis.  If  the  fat  remains  in  the  smaller  arteries  of 
the  lung  and  the  heart  action  is  not  strong  enough  to  drive  the  foreign 
mass  into  the  general  circulation  (Ribbert),  the  symptoms  are  limited 
to  the  lungs.  If,  however,  the  fat  is  driven  through  the  capillaries  into 
the  general  circulation,  other  viscera,  especially  the  brain  and  heart, 
become  involved.  To  the  symptoms  already  described  will  then  be 
added  those  of  severe  cerebral  disturbances  (delirium,  convulsions,  vom- 
iting, paralysis,  and  coma),  following  multiple  small  hamiorrhages  into 
the  brain,  and  acute  cardiac  weakness,  following  degeneration  of  the 
heart  muscle.  Frequently  there  is  some  fever,  due  in  some  cases  to 
a  beginning  pneumonia,  in  other  eases  to  interference  with  the  heat 
center  by  ha?morrhages.  The  haemorrhages  may  also  cause  a  fall  in 
temperature   (Czerny,  Scriba). 

In  the  severe  cases  death  occurs  in  a  few  days.  The  mild  cases 
gradually  recover  as  the  fat  is  absorbed. 

Diagnosis. — The  diagnosis  of  fat  embolism  can  be  made  with  a  fair 
degree  of  certainty  if  pulmonary  or  cerebral  symptoms  develop  soon 
after  an  injury  to  bone  in  a  person  who  just  before  the  injury  was  in 
good  physical  condition,  and  if  fat  droplets  can  be  demonstrated  in  the 
urine.  Pulmonary  embolism  caused  by  the  setting  loose  of  venous  em- 
boli at  the  seat  of  fracture  develops  much  later,  usually  not  before  the 
third  week  following  the  injury. 

Pathology. — It  has  been  found  in  cases  examined  shortly  after 
death  that  the  capillaries  and  smaller  vessels  were  filled  with  fat 
droplets. 

Treatment. — The  condition  should  be  treated  symptomatically.  The 
fracture  should  be  carefully  immobilized  to  prevent  more  fat  from 
entering  the  circulation,  and  remedies  should  be  administered  to  sustain 
the  heart's  action,  camphorated  oil,  ammonia,  and  digitalis  probably 
being  the  best  drugs  for  this  purpose. 

Literature. — Ahrcns.  Todliche  Fettenibolien  nach  gewaltsamer  Streckung  bcitlcr 
Kniegelenke.  Beitr.  z.  klin.  Chir.,  Bd.  14,  1895,  p.  235. — v.  Bcryinann.  Ziir  Lehre 
der  Fettembolie,  Habilitationsschrift,  Dorpat,  1863. — v.  Bruns.  Die  Lehre  vonden 
Knochenbriichen.  Deutsche  Chir.,  1886,  Fettembolie,  p.  477. — Ilaemig.  Ueber  die 
Fettembolie  des  Gehirnes.  Beitr.  z.  klin.  Chir.,  Bd.  27,  1900,  p.  333,  with  Lit.— Payr. 
Zur  Kenntnis  imd  Erkliirung  des  fettembolischen  Todes  nach  orthopadischen  Eingriffen 
und  Verletzungen.  Zeitschr.  f.  Orthopadie,  Bd.  7,  1900,  p.  338. —  Preindelsberyer.  Ein 
Fall  von  Fettembolie  nach  Redressement.  Zeitschr.  f.  Heilkvmdc,  Bd.  24,  1903. — 
Ribbert.     Zur  Fettembolie.     Deutsche  med.  Wochenschr.,  1900,  p.  419. 


642  GENERAL   RESULTS   OF    INJURIES 

CHAPTER    IV 

TRAUMATIC    DIABETES 

It  has  been  shown  by  the  physiological  experiments  of  Claude  Ber- 
nard that  injury  of  a  definite  area  in  the  floor  of  the  lower  part  of 
the  fourth  ventricle,  between  the  points  of  origin  of  the  vagus  and  audi- 
tory nerves,  is  followed  in  a  few  hours  by  glycosuria  if  the  center 
controlling  the  vasomotor  nerves  of  the  liver  is  injured,  by  polyuria  if 
that  controlling  the  vasomotor  nerves  of  the  kidney  is  affected. 

Disturbances  of  sugar  metabolism  and  of  the  mechanism  controlling 
the  excretion  of  urine  are  not  infrequently  observed  after  injuries  (espe- 
cially after  injuries  of  the  head,  after  fractures,  and  injuries  of  the 
pancreas,  liver,  kidney).  As  a  rule,  these  disturbances  develop  a  few 
days  after  the  injury.  It  cannot  be  demonstrated,  however,  that  there 
is  any  lesion  of  the  centers  above  mentioned.  The  glycosuria  is  tran- 
sitory, subsiding  usually  within  a  week.  The  urine  which  is  secreted 
never  contains  more  than  one  per  cent  of  sugar.  A  true  diabetes  mel- 
litus  or  insipidus  occasionally  develops  after  an  injury.  They  are  much 
rarer  than  the  temporary  glycosuria  above  mentioned. 

Nothing  definite  is  known  concerning  the  nature  and  cause  of  trau- 
matic glycosuria. 

The  treatment  is  conducted  along  the  lines  prescribed  in  internal 
medicine. 

Literature.  Kausch.  Beitriige  zum  Diabetes  in  der  Chirurgie.  Chir.-Kongr. 
VerhantU.,  1904,  II,  p.  650. — Morris.  Diabetes  in  Surgery.  Medical  News,  1901, 
June,  29. 


PART   V 


IMPORTAISTT    SURGICAL    DISEASES,   EXCLUD- 
ING  LNEECTIOIvrS   ATsD   TUMORS 


CHAPTER    I 

DISEASES    OF    THE    SKIN    AND    MUCOUS    MEMBRANES 

(a)  CONGENITAL   SKIN   DEFECTS 

Congenital  defects  of  the  skin  appear  in  a  number  of  different 
forms,  usually  associated  with  disturbances  in  development.  Besides 
fissures  and  fistula?  resulting  from  incomplete  fusion  of  embryonal  clefts, 
there  are  also  adhesions  between  different  parts  of  the  body  which  are 
also  to  be  regarded  as  developmental  defects. 

Cutaneous  syndactylism,  in  which  neighboring  fingers  are  contained 
in  a  connnon  cutaneous  envelope  or  are  connected  by  a  membrane  re- 
sembling a  web  of  a  goose  foot,  belongs  to  the  latter  class  of  anomalies. 
Broad  cutaneous  adhesions  resembling  a  wing  occur  in  the  popliteal 
space,  in  the  axillary  fossa,  and  between  the  neck  and  chest.  These 
malformations  are  frequently  associated  with  muscular  anomalies  and 
other  developmental  defects. 

Small  nodules  about  the  size  of  a  pea,  occurring  in  the  skin  at  birth, 
may  be  the  remains  of  adhesions  between  the  area  in  which  the  nodule 
appears  and  the  amnion.  Deep  fui-rows  in  the  face  and  upon  the 
extremities,  which  may  even  extend  down  to  the  ])one,  may  be  caused 
by  the  constriction  of  anniiotic  bands.  These  may  be  circular  and  extend 
deep  enough  to  amputate  the  extremity. 

Plastic  operations  of  different  sorts  are  often  required  to  repair  the 
fissures  and  to  overcome  the  adhesions.  Abnormal  appendages  of  the 
skin  and  fistulse  should  be  excised. 

(b)  ECZEMA 

The  most  superficial  inflammati<jns  of  the  skin  are  grouped  under 
the  term  eczema.     They  are  of  interest  to  the  surgeon  in  a  number  of 

64.3 


644       SURGICAL   DISEASES,   EXCLUDING  INFECTIONS   AND   TUMORS 

different  ways.  An  eczema  interferes  with  wound  repair.  In  some 
cases  one  is  compelled  to  operate  upon  skin,  the  seat  of  an  eczema  (e.  g., 
an  intertrigo  of  the  slvin  covering  a  strangulated  hernia),  and  occa- 
sionally the  eczema  develops  later  when  the  skin  is  bathed  with  secre- 
tion from  a  deep  infected  wound  in  bone  or  when  it  is  exposed  to  the 
action  of  iodoform.  An  eczema  caused  by  sublimate  solution  occasion- 
ally develops  upon  the  surgeon's  hand  which  incapacitates  him  for  some 
time,  as  the  vesicles  and  pustules  developing  upon  the  moist,  scaling, 
and  fissured  area  render  asepsis  impossible,  even  when  the  greatest 
precautions  are  taken.  The  diseased  area  may  also  furnish  the  infection 
atrium  for  pyogenic  infections  (lymphangitis,  thrombophlebitis,  etc.). 

Causes  of  Eczema. — The  causes  of  eczema  are  external  and  internal. 
Mechanical  irritation  by  rubbing  of  opposed  sweating  surfaces  (inter- 
trigo or  chafing  of  the  scrotum  and  thigh,  in  the  groin  and  axillary 
fossa,  and  beneath  large  dependent  breasts),  or  by  scratching  in  scabies, 
urticaria,  prurigo,  and  insect  bites;  chemical  irritation,  especially  by 
agents  used  for  sterilization  and  in  susceptible  patients  by  iodoform ; 
and  thermal  changes  produced  by  radiating  heat  or  dry  cold  are  the 
external  causes. 

Eczema  may  appear  as  a  symptom  in  a  number  of  conditions,  such 
as  icterus,  diabetes,  nephritis,  chlorosis,  and  dysmenorrhcea.  These  may 
be  regarded  as  some  of  the  internal  causes. 

Different  Forms. — Eczema  appears  in  a  number  of  different  forms,  one 
frequently  passing  into  another.  The  skin  itches  severely  and  becomes 
red  (eczema  erythematosum),  and  small  red  nodules  which  never  become 
larger  than  a  pinhead  (eczema  papulosum)  may  then  develop.  Vesicles 
may  develop  from  these  nodules  (eczema  vesiculosum),  and  if  the  con- 
tents of  these  vesicles  become  purulent  a  pustular  eczema  (eczema  pustu- 
losum)  develops.  If  the  epidermis  is  lost  as  the  result  of  long-continued 
irritation  or  maceration  a  weeping  surface  remains,  weeping  eczema  (ec- 
zema madidans).  When  the  serum  dries  the  area  becomes  covered  with 
crusts,  or,  if  pus  develops  beneath  the  crusts,  with  pustules  resembling 
those  seen  in  impetigo.  ["  It  is  important  to  remember  that  an  attack  of 
acute  eczema,  like  other  acute  diseases,  may  subside  spontaneously,  and 
that  this  is  not  less  likely  to  happen  because  the  eruption  is  extensive. 
The  eruption  may  become  abortive  in  the  first  stage  (when  it  resembles 
a  papular  erythema)  and  end  with  desquamation,  or  after  exudation  has 
taken  place.  This  may  gradually  become  less  and  dry  up,  when,  after 
a  few  exfoliations,  the  skin  becomes  sound.  The  possibility  of  spon- 
taneous subsidence  should  always  be  kept  Iti  mind,  and  be  a  warning 
against  too  energetic  treatment.  But  unfortunately,  in  accordance  with 
the  observed  pi-oclivities  of  eczema,  it  more  often  ha]^pens  that  tlie  acute 
I)asses  iiilo  ;i  cliroiiic  inlljiiniiiiilioii,  whicli  i'e(|uii'(>s  the  ti'eatment  ajipro- 


DISEASES   OF   THE   SKLN    AND   MUCOUS  MEMBRANES  045 

priate  for  that  form."— T.  C.  Allbutt,  "  System  of  Medicine,"  Vol.  IX, 
p.  508.] 

Most  Common  Sites  for  Development. — Eczema  develops  most  fre- 
({ueiitly  upon  the  face,  head,  neck,  b.ands  and  feet,  the  external  geni- 
talia, in  the  axillary  fold,  and  in  fat  people  in  all  the  deep  cutaneous 
folds.  Eczema  also  develops  frequently  in  poorly  nourished  parts,  in 
paralyzed  parts,  over  large  tumors,  and  in  skin  the  seat  of  chronic 
a'dema  and  elephantiasis. 

Treatment. — The  treatment  which  should  be  in.stituted  depends  upon 
the  cause.  The  cause  should  be  removed  and  the  affected  area  should  be 
protected  from  injuries,  among  which  rubbing  and  scratching  provoked 
by  the  severe  itching  are  the  most  dangerous.  The  milder  acute  forms 
are  usually  controlled  by  a  generous  application  of  boric  acid  or  zinc 
oxid  ointment,  which  should  be  covered  with  enough  dressings  to  protect 
the  area.  In  the  treatment  of  scaling  chronic  eczemas,  it  is  generally 
best  to  employ  preparations  of  tar.  The  eczema  developing  upon  a  sur- 
geon's hands,  which  usually  can  be  prevented,  is  readily  controlled  by 
the  use  of  a  ten  per  cent  zinc  vaseline  ointment  and  by  wearing  gloves 
until  the  lesions  are  healed. 

(c)  (EDEMA   OF   THE   SKIN   AND   MUCOUS   MEMBRANES 
(EDEMA    OF    THE    SKIN 

The  fluids  found  in  the  tissue  spaces,  which  are  filtered  from  the 
blood  by  the  secretory  activity  of  the  cells  of  the  capillary  walls,  and  are 
again  taken  up  by  the  lymphatic  vessels,  may  in  certain  diseased  con- 
ditions collect  in  the  tissues  and  body  cavities.  If  the  fluid  collects  in 
the  cavities,  one  speaks  of  a  hydrops  artieularis,  a  hydrothorax,  a  hydro- 
pericardium,  or  an  ascites,  depending  upon  the  cavity  involved.  If 
the  viscera,  the  skin,  or  mucous  membrane  are  saturated  with  these 
fluids  one  speaks  of  an  oedema,  or  if  a  large  part  of  the  surface  of  the 
body  is  involved  of  an  anasarca. 

Causes  of  CEdema. — Venous  stasis  and  disturhed  capillary  secretion 
are  the  most  important  causes  of  a^dema.  Lymph  stasis  is  a  much  rarer 
cause. 

In  venous  stasis  there  is  an  increased  formation  of  lymph,  as  the 
result  of  increased  pressure  in  the  capillaries.  If  the  venous  stasis 
continues  for  some  time,  nutritional  disturbances  develop,  the  tissues 
lose  their  tone,  and  then  the  noi-mal  movements  of  the  lymph  are  inter- 
fered with  and  the  eai)illary  walls  become  more  ])ei"iii('nble. 

CEdema  follows  occlusion  of  tlic  large  veins  of  the  ti'unk  and  ex- 
tremities, unless  the  occlusion  occurs  slowly  enough  to  permit  of  the 
development  of  a  collateral  circulation.     The  oedema  which  develops 


646       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND   TUMORS 

after  the  ligation  of  veins  is  apt  to  be  transitory.  After  occlusion  by  a 
thrombus,  or  by  the  pressure  of  a  tumor,  the  oedema  is  apt  to  be  more 
permanent  as  the  openings  of  the  veins  entering  into  the  collateral 
circulation  are  apt  to  be  occluded.  A  transitory  oedema  frequently  de- 
velops in  an  extremity  which  has  been  immobilized  for  some  time,  when 
attemj^ts  are  made  to  use  it  again.  This  is  due  to  the  impairment  of 
venous  circulation,  following  a  temporary  atrophy  of  the  muscles. 

Disturbance  of  capillary  secretion  is  the  cause  of  a  number  of  dif- 
ferent forms  of  oedema.  The  alterations  in  capillary  secretion  are  either 
the  results  of  nutritional  disturbances,  or  of  toxic,  chemical,  thermal,  or 
traumatic  injuries  to  the  endothelium  of  the  capillaries.  As  a  result 
of  such  an  injury  the  vessel  M'all  acts  mechanically  like  a  filter.  The 
less  the  tension  of  the  tissues,  which  is  lowered  by  the  same  causes  that 
injured  the  vessels,  and  the  higher  the  blood  pressure,  the  more  rapidly 
the  fluids  are  poured  out. 

Clinical  Forms, — Inflammatory  cedema  accompanying  inflammation 
of  bacterial,  toxic,  and  mechanical  origin  develops  in  different  degrees 
in  the  skin,  mucous  membranes,  and  viscera. 

Hydrcemic,  cachectic,  or  marantic  oedema  occurs  in  those  diseases 
characterized  by  hydra^mia.  The  hydra?mia  may  be  due  to  a  decrease 
in  the  albumen  content  of  the  blood  (in  ana?mia,  cachexia  associated 
Avith  chronic  infectious  diseases  and  malignant  tumors)  or  to  an  increase 
of  water  in  the  blood  (nephritis  and  cardiac  insufficiency).  Neuropathic 
oedema  occurs  occasionally  in  hysteria. 

Myxoeclema  belongs  to  the  chemical  oedemas.  It  develops  when  the 
secretory  activity  of  the  thyroid  gland  is  greatly  diminished  or  after  its 
complete  removal.  The  changes  are  most  marked  in  the  skin  of  the 
face  and  extremities.  The  fluid,  which  is  deposited  in  the  subcutaneous 
tissues  and  gives  it  the  tense,  somewhat  doughy  feel,  resembles  mucin ; 
therefore  the  term  myxoeclema.  This  condition  may  be  relieved  by  the 
feeding  of  thyroid  extract  (thyroid  tablets)  prepared  from  the  thyroid 
glands  of  calves  or  .sheep. 

(Edema  due  to  lymph  stasis  develops  only  after  the  occlusion  of  the 
large  lymphatic  ducts  of  the  extremities  or  of  the  thoracic  duet.  Lymph 
(edema  of  the  lower  extremity  and  scrotum  nuiy  follow  the  extirpation 
of  inflamed  inguinal  lymph  nodes,  the  collateral  vessels  being  closed  by 
thrombi.    Occlusion  of  the  thoracic  duct  is  usually  caused  by  neoplasms. 

G'Jdema  ex  vacuo  occurs  principally  in  the  cranial  cavity  and  spinal 
carKil.  Tt  develops  in  all  cases  in  Avhicli  a  portion  of  the  brain  and 
spiiKiI  coi-d  is  lost  and  its  phicc  is  not  taken  l)y  some  other  tissue. 

Appearance  of  CEdematous  Area, — In  (edema  of  the  skin  the  sul)cu- 
tancous  tissues  are  also  involved,  for  their  anatomical  structure  permits 
of  the  accumulation  of  large  amounts  of  fluid.     Not  infrequently  the 


DISEASES   OF   THE   SKIN   AND   MI'COUS  MEMBRANES  647 

liuid  extends  from  subcutaneous  into  the  loose  intermuscular  tissues. 
An  a-dematous  area  is  swollen,  the  swelling  gradually  being  lost  in  the 
surrounding  healthy  tissues,  and  the  slvin  is  cool  and  of  a  waxy  appear- 
ance. The  skin  has  a  bluish  color  only  when  there  is  a  venous  stasis. 
The  movements  of  an  u'dematous  extremity  are  restricted.  It  feels 
heavy  and  becomes  easily  exhausted  when  movements  are  made.  If 
an  incision  is  made  in  an  a^dematous  part  a  clear  fluid  pours  out  from 
the  cut  surface,  the  conditions  being  very  similar  to  those  found  in  an 
area  when  infiltration  amesthesia  has  been  employed. 

Development  of  (Edema.— An  oedema  of  the  skin  never  develops  sud- 
denly. The  fluid  collects  gradually  and  the  swelling  develops  slowly. 
The  time  required  for  the  swelling  to  reach  its  maxinuuii  development 
naturally  varies  in  the  difl'erent  cases.  The  oedema  is  not  permanent 
if  the  cause  can  be  removed  or  its  action  is  only  transitory.  Chronic 
oedema  leads  to  trophic  disturbances  in  the  skin,  and  the  latter  becomes 
rough  and  fissured.  As  the  result  of  the  stimulation  and  proliferation 
of  the  su])cutaneous  tissues  a  pachydermia  may  follow  a  chronic  oedema. 

Differential  Diagnosis. — An  oedema  can  usually  be  easily  dift'eren- 
tiated  from  other  somewhat  similar  conditions,  such  as  the  tliickening 
of  the  skin  associated  with  elephantiasis,  diffuse  lipomatosis,  lymphan- 
giomas, and  recent  deeply  seated  ha-matomas.  An  cedenux  pits  upon 
pressure,  as  the  fluids  are  driven  out  of  the  meshes  of  the  subcutaneous 
tissue,  and  the  pit  that  remains  when  the  pressure  is  removed  disap- 
pears slowly,  as  some  time  is  required  for  the  meshes  to  flU  again.  Pit- 
ting upon  pressure  and  the  slow  disappearance  of  the  pit  are  character- 
istic of  fed  em  a. 

Treatment. — In  treating  an  oedema,  naturally,  the  cause  sliould  flrst 
be  removed  and  the  venous  circulation  should  be  assisted  and  improved 
by  elevation  of  the  extremity  and  by  the  application  of  an  elastic  band- 
age, exerting  mild  compression,  from  the  periphery  toward  the  trunk. 
In  hydra?mic  oedemas  the  disease  to  which  the  oedema  is  secondaiy  slioidd 
receive  proper  treatment  and  the  general  condition  shoidd  be  improved. 
Frequently  the  latter  is  impossible,  as  the  a>dema  is  an  indication  of  the 
beginning  of  the  end.  IMassage  is  of  advantage  in  the  treatment  of  all 
forms  of  wdema  of  the  skin,  excepting  those  associated  with  inflam- 
mation and  thrombosis.  A  long-continued  inflammatory  oedema  is  often 
benefited  by  hydrotherapy,  which  may  also  be  of  value  in  chronic 
oedema  due  to  other  causes. 

CEDEMA    OF    MUCOUS   MEMBRANES 

An  oedema  of  mucous  membranes  is  associated  with  either  infamma- 
tion  or  circulatory  disturbances.  If  it  develops  acutely  as  the  result 
of  severe  inflammation  or  sudden  stasis,  the  infiltration  of  the  mucosa 


648       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND   TUMORS 

and  submucosa  causes  a  marked  swelling,  which  in  the  upper  air  i)as- 
sage  may  produce  marked  disturbances.  CEdema  of  the  nasal  mucous 
membranes,  rendering  nasal  breathing  impossible,  and  swelling  of  the 
uvula  are  constant  accompaniments  of  nasopharyngeal  catarrh.  QEdema 
of  the  glottis  may  be  associated  with  catarrhal  and  diphtheritic  inflam- 
mations, submucous  phlegmons,  and  ulcers  of  laryngeal  mucous  mem- 
brane. It  may  develop  secondary  to  inflammatory  processes  adjacent 
to  the  larynx  and  may  follow  stasis  due  to  the  ligation  of  large  vessels 
(in  operations  about  the  larynx).  The  sw^elling  in  this  condition  may 
interfere  with  respiration  and  threaten  the  life  of  the  individual. 

Surgical  Significance  of  (Edema. — The  chronic  redema  which  is  asso- 
ciated with  general  venous  stasis  (in  heart  disease  and  emphysema  of 
the  lungs),  or  follows  occlusion  or  compression  of  the  veins  draining  the 
mucous  membrane  is,  as  a  rule,  of  less  surgical  significance  than  the 
chronic  inflammatory  oedema.  The  latter  leads,  especially  in  the  nose 
and  accessory  sinuses,  to  thickenings,  and  to  the  development  of  con- 
nective tissue  and  pedunculated  growths,  the  so-called  polyps.  Besides 
mucous  membranes  stimulated  to  proliferation  by  continued  irritation 
afford  a  favorable  base  for  the  development  of  a  number  of  different 
forms  of  tumors,  such  as  papillomas,  fibromas,  adenomas  (in  the  form 
of  polyps),  and  carcinomas.  Leucoplakia  of  the  mucous  membranes  of 
the  mouth  upon  which  carcinoma  of  the  tongue,  cheeks,  and  lips  fre- 
quently develop  is  apparently  caused  by  chronic  irritation  (tobacco 
smoking) . 

Treatment. — The  same  methods  should  be  followed  in  treating  inflam- 
matory a'denia  of  the  mucous  membranes  as  have  been  described  in  dis- 
cussing acute  and  chronic  inflammations  of  the  same.  A  marked  a?dema 
due  to  stasis  frequently  subsides  rapidly  after  multiple  small  incisions 
have  been  made.  An  oedema  of  the  glottis  may  threaten  life  and  demand 
immediate  tracheotomy. 

(d)  ELEPHANTIASIS 

The  condition  known  as  elephantiasis  Arabum — to  distinguish  it 
from  elephantiasis  Gra?corum  (leprosy) — and  as  acquired  pachydermia 
is  characterized  by  a  thickening  of  the  skin  and  subcutaneous  tissues 
of  different  parts  of  the  body.  In  advanced  cases  the  deeper-lying  con- 
nective tissues  may  also  be  involved.  The  thickening  of  the  skin  and 
development  of  connective-tissue  masses  produce  unsightly  deformities 
of  the  part  involved. 

Pathology. — Pathologically,  two  processes — a  chronic  inflammatory 
proliferation  of  the  connective  tissues  and  a  dilatation  of  the  lymphatic 
vessels — are    combined.      Long-continued    inflannnatorv    irritation    and 


DISEASES   OF   THE   SKIX   AND   MUCOUS   MEMBRANES 


649 


local  circulatory  disturbances  are  the  causes.  Tliickening,  obliteration, 
and  dilatation  of  the  veins  and  alterations  in  the  skin  are  also  contribut- 
ing causes. 

Clinical  Course.— Elephantiasis  develops  slowly,  the  clinical  course 
extending  over  niontlis  and  years.  It,  as  a  rule,  develops  from  a 
chronic  oedema  following 
the  radical  removal  of 
suppurating  lymph  nodes 
or  the  dilatation  or  throm- 
bosis of  a  large  number 
of  veins.  Elephantiasis 
due  to  these  caiLses  de- 
velops most  commonly  in 
the  scrotum  and  lower  ex- 
tremities. Some  cases  of 
elephantiasis  follow  re- 
peated acute  infiannnations 
of  the  skin  and  subcuta- 
neous tissues,  especially 
erysipelas,  lymphangitis, 
and  thrombophlebitis.  Af- 
ter each  attack  the  thick- 
ening of  the  skin  becomes 
somewhat  more  pronounced. 
These  inflammatory  proc- 
esses develop  from  a 
chronic  eczema,  tubercu- 
lous and  gummatous  ul- 
cers, or  from  fistulas  lead- 
ing to  suppurating  bone 
cavities,  and  are  generally 
associated  with  a  lymph- 
adenitis. According  to 
llnna,  streptococcic  inflam- 
mations are  the  ones  which 
most  often  leave  connec- 
tive-tissue growths.  Ele- 
phantiasis due  to  dilata- 
tion or  obliteration  of  the  veins  is  most  commonly  seen  in  the  lower 
extremities  (especially  associated  with  varicose  ulcers  or  the  chronic 
eczema  accompanying  varicose  veins  and  thi'ombophlebitis),  upon  the 
scrotum,  the  penis,  the  female  external  genitalia,  and  the  face  (lips 
and  lids). 

42 


Fig.  240. — Elephantiasis  of  the  Left  Lower  J-X- 

TKEMITY  IN  A  WoMAN  FiFTY  YeAUS  OP  AgE.       Tlie 

skin  is  covered  with  thick  crusts  and  is  traversed 
by  hard,  tuniorhke  masses.  Ligation  of  the  femo- 
ral artery  eavc  no  results. 


650       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 

Clinical  Appearance. — The  thickening  of  the  skin  is  sometimes  even 
and  synnnetrical,  while  at  other  times  large  masses  which  resemble 
tumors  in  appearance  and  in  their  independent  growth  are  formed  by 
transverse  furrows  {vide  Fibromas).  If  the  skin  is  not  raised  to  form 
folds,  it  remains  firmly  attached  to  the  subcutaneous  tissues.  Pigmen- 
tation, the  formation  of  scales  following  increased  proliferation  of  the 
horny  layer  of  the  skin,  in  many  places  (especially  upon  the  scrotum) 
the  development  of  vesicles  by  dilatation  of  the  superficial  lymphatics 
and  lymphorrha^a  (so-called  lymph  scrotum),  the  formation  of  crusts 
following  desiccation  of  the  secreticms,  eczema,  fissures,  ulcers,  and  paj)il- 
lomatous  growths  accompany  the  connective-tissue  proliferation  and 
produce  a  bizarre  clinical  picture  which  may  be  altered  from  time  to 
time  by  the  developmentof  acute  inflammatory^  processes  (lymphangitis, 
phlegmons,  erysipelas,  lymphadenitis).  The  connective-tissue  prolifera- 
tion gradually  involves  the  muscles,  the  contractile  substance  of  which 
becomes  atrophic.  Finally  the  soft  tissues  become  converted  into  a  dense, 
indurated,  or  soft  gelatinouslike  mass  (elephantiasis  dura  or  molle) 
which  is  often  traversed  by  large  dilated  lymphatic  si)aces  (elephantiasis 
lymphangiectatica).  The  size  of  the  bones  of  the  part  involved  may  be 
increased  by  periosteal  bone  formation. 

Clinical  Forms. — Endemic  Elephantiasis. — An  endemic  form  of  ele- 
phantiasis occurs  in  the  tropics  (Arabia,  Egypt,  Hindustan,  Central 
America,  etc.).  The  disease  begins  insidiously  or  with  acute  febrile 
attacks  of  lymphangitis.  The  changes  occur  in  one,  more  rarely  both, 
lower  extremities,  in  the  scrotum  and  penis,  sometimes  in  the  arms, 
the  external  female  genitalia,  the  head,  and  breast.  Sometimes  rapidly, 
at  other  times  more  slowly,  the  parts  affected  attain  a  ■size  and  form 
scarcely  ever  seen  in  sporadic  elephantiasis.  The  scrotum  may  be  trans- 
formed into  an  unshapely,  heavy  mass,  upon  the  surface  of  which  the 
drawn-out  and  invaginated  skin  of  the  penis  forms  a  canal  leading 
down  to  the  opening  of  the  urethra.  Lymphadenitis  and  phlegmons 
developing  from  a  lymphangitis  are  common  during  the  course  of  the 
disease. 

Filaria  Sanguinis  Hnminis. — Some  of  the  cases  of  this  form  of  ele- 
phantiasis are  caused  by  infections  with  the  filaria  sanguinis  hominis 
(Bancroft).  In  some  other  cases  the  cause  is  unknown.  Filaria 
sanguinis  is  a  term  applied  to  the  Inrva^  of  a  worm,  which,  when 
sexually  mature,  is  filiform  and  measures  from  8  to  10  cm.  in  length. 
The  larva'  are  0.85  mm.  long  and  occur  in  the  blood  and  lymph  of 
man.  According  to  Manson  the  larva^  are  apparently  transferred  to 
inan  by  the  sting  of  mos(|uitoes.  They  then  gain  access  to  and  de- 
velop in  the  lymph  vessels,  producing  a  lymph  stasis  associated  with 
itilhiiiiination. 


•      DISEASES   OF   THE    SKIX    AM)   MICOUS   MEMBRANES  651 

Elephantiasis  does  not  always,  however,  follow  iufeetions  with  filaria 
sanguinis  hominis.     The  larvcT  may   be  deposited  by  the  blood  in  the 


•aS3aBncw^B»»> 


z::^'^^^'^ 


Fig.  241. — Ki,i:ph.\nti.\sis  of  the  Scrotum.      (Xativ.    ,.i   .l:i\; 


kidneys,    causing   ha-iuatnria.      Chyluria   and   cludous    diarrluea    folh 
occlusion  of  the  thoracic  duct. 


652       SURGICAL   DISEASES,    EXCLUDING   INFECTIONS   AND   TUMORS 


Acquired  elephantiasis  or  pacliyderniia  may  be  confused  with  the 
congenital  elephantous  forms  of  lymphangioma,  hemangioma,  and  fibro- 
mas  involving  nerves  (vide  Tumors,  Part  VI). 

An  accurate  history  as  to  the  previous  clinical  course  enables  one 
to  make  a  positive  diagnosis.  Partial  giant  growth  is  easily  differen- 
tiated, as  in  the  former  the  bones  are  also  enlarged. 

Congenital  Thickening  of  the  Skin. — Congenital  thickening  of  the 
skin  and  subcutaneous  tissues  of  the  extremities  following  constriction 
produced  by  amniotic  bands  is  seen  quite  frequently  upon  the  extremi- 
ties. In  these  cases  the  bones  are  not  enlarged.  The  cause  of  these 
changes  is  an  interference  with  venous  circulation  occurring  during 
gestation. 

BJiinophyma. — Rhinophyma,  Avhich  develops  in  old  people  (espe- 
cially heavy  drinkers)  and  is  characterized  by  an  elephantous  thicken- 
ing of  the  skin  of  the  nose, 
is  a  special  form  of  ele- 
phantiasis, usually  develop- 
ing upon  an  acne  rosacea 
(Fig.  242).  While  dark 
red  macules  or  soft  nodules 
transversed  by  widely  di- 
lated capillaries  develop 
upon  other  parts  of  the 
face,  large  red  tumorlike 
masses  and  lobulated 
growths,  Avhich  histologi- 
cally are  characterized  by 
a  connective-tissue  hyper- 
plasia, form  upon  the  nose. 
These  masses  consist  of  hy- 
perplastic connective  tis- 
sue, dilated  blood  vessels, 
and  sebaceous  glands  which 
are  hypertrophic  or  have 
undergone  cystic  degenera- 
tion. It  differs  from  other 
forms  of  eleplijiiitous  new  growths,  in  that  the  changes  are  limited 
to  the  nose.  The  hair  follicles  in  and  adjacent  to  such  a  growth  are 
either  undergoing  suppurative  changes  or  appear  as  deep  dilated  pores, 
giving  to  the  dark  red  soft  growth  a  spongelike  appearance.  There  are 
a  juimber  of  different  vicnvs  concerning  the  cause  of  rhinophyma.  Ile- 
bra  regards  the  connective-tissue  changes  as  primary,  Lassar  believes 
the  degeneration  of  the  sebaceous  glands  and  the  inflammation  of  the 


Fig.   242. — Hiiinophyma. 


DISEASES  OF  THE  SKIN  AND  MtX'OUS  MEMBRANES  653 

tissue  about  them  to  be  the  essential  cause,  while  Lesser  believes  that 
(lihitation  of  the  blood  vessels  yives  the  stimulus  to  conneetive-tissue 
growth.  Kaposi  aud  Uohi  regard  rhinophynia  as  au  angioneurosis,  the 
circulatory  changes  causing  connective-tissue  hyperplasia.  In  some 
cases  the  essential  cause  is  probably  congenital. 

Khinophyma  has  been  operated  upon  with  considerable  success,  part 
of  the  mass  being  removed  with  a  knife,  or,  because  of  profuse  bleeding, 
Avith  a  thermocautery.  Dieffenbach  obtained  an  exceptionally  good 
result  in  an  aggravated  case  by  cuneiform  excisions  of  tissue  (Fritze 
and  Keich).  If  large  defects  remain  after  removal  of  tissue,  they  may 
be  covered  with  skin  grafts  or  granulation  tissue  may  be  allowed  to 
develop,  new  epithelium  growing  from  the  remaining  sebaceous  glands 
to  cover  it  (Rusch). 

Treatment. — The  condition  may  be  improved  if  the  tumorlike  folds 
and  masses  are  removed.  The  penis  and  scrotmn,  if  very  large,  should 
be  amputated.  Fusiform  excision  of  the  skin  of  the  face  or  extremities, 
when  involved,  is  of  great  value.  The  results  following  ligation  of  the 
principal  artery  (e.  g.,  in  elephantiasis  of  the  lower  extremity  ligation 
of  the  femoral  or  external  iliac),  which  was  introduced  by  Carnochan 
(1851)  and  especially  reconnnended  by  Ilueter  (1868),  are  always 
doubtful.  In  inoperable  cases  the  circidation  should  be  improved  by 
elevation  of  the  limb,  massage,  bandages,  and  adhesive  strips.  Alcohol 
injections  may  also  be  employed  with  a  view  of  obliterating  the  vessels 
and  causing  a  contraction  of  the  newly  formed  tissues.  The  eczema  and 
fissures  should  receive  appropriate  treatment.  Extensive  phlegmons, 
exhausting  inflammatory  processes  and  ulcers  which  will  not  heal  may 
render  amputation  necessary. 

Literature. — Basch.  Ueber  sogenannte  Flughautbildung  beini  INIenschen.  Zeitschr. 
f.  Heilk.,  Bd.  12,  1891,  p.  499.— i;.  Bruns.  Ueber  das  Rhinophyma.  Beitr.  z.  klin. 
Chir.,  Bd.  39,  1903,  p.  1. — v.  Esmarch  und  Kulenkampff.  Die  elephantiastischen  Fornien. 
Hamburg,  1885. — Friedrich.  Pachyderniie  iin  Anschlusse  an  habituelles  Gesichts- 
erysipel.  Miinch.  med.  Wochenschr.,  1897,  p.  33. — -Funke.  Pterygium  colli.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  63,  1902,  p.  162.— Frifse  und  Reich.  Die  plastische  Chirurgie. 
Berlin,  1845. — Klaussrier.  Ueber  Missbildungen  d.  nienschl.  Cdiedmassen.  N.  F., 
Wiesbaden,  1905,  p.  9. — Landcrer.  Die  Gewebsspannung.  Leipzig,  1884. — Lesser. 
Lehrbuch  der  Hautkrankheiten.  Leipzig,  1901. — Manson.  The  Filaria  Sanguinis  and 
Certain  New  Forms  of  Parasitic  Diseases.  London,  1883; — The  Fihiria  Sanguinis  Homi- 
nis  Major  and  Minor,  etc.  Lancet,  1891,  p.  4. — Rusch.  Zur  operativen  BehantUung  des 
Rhinophyma.  Wien.  khn.  Wochenschr.,  1902,  p.  333. — Schcube.  Die  Krankheiten  der 
warmen  Lander.  Jena,  1900. — Unna.  Histopathologic  der  Hautkrankheiten.  Berhn, 
1894. — V.Winiwarter.     Die  chirurgischen  Krankheiten  der  Haut.     Deutsche  Chir.,  1892. 


654       SURGICAL   DISEASES,   EXCLUDING   INFl':CTIONS   AND  TUMORS 

CHAPTER    II 

DISEASE   OF   MUSCLES   AND   TENDONS 

(a)  CONGENITAL  MUSCULAR   DEFECTS 

A  coNGENiTxVL  miisciilar  defect  exists  if  there  is  an  anomalous  inser- 
tion or  complete  absence  of  a  muscle  (e.  g.,  anomalous  insertion  of  the 
tibialis  anterior  or  of  the  extensor  digitorum  communis).  The  result- 
ing disturbance  in  motion  is  not  to  be  mistaken  for  paralysis.  Malfor- 
mations, such  as  syndactylism,  polydactylism,  or  defects  in  bone  may 
give  a  clew  to  the  diagnosis.  Congenital  absence  of  the  trapezius,  which 
has  been  demonstrated  in  the  congenital  high  position  of  the  scapula, 
has  been  shown  to  be  the  cause  of  this  deformity. 

(b)  ATROPHY  OF  MUSCLES,  SIMPLE  AND  DEGENERATIVE 

Anatomically  a  simple  is  distinguished  from  a  degenerative  atro- 
phy of  muscle  fibers.  In  the  former  the  muscle  fibers  decrease  in  size 
and  nu?nber,  and  no  other  anatomical  changes  can  be  demonstrated. 
In  the  degenerative  atrophy  a  number  of  different  pathological  proc- 
esses may  be  combined,  such  as  fragmentation  and  segmentation  of  the 
fibrillae,  fatty  degeneration,  coagulation,  or  liquefaction  of  the  myo- 
plasm.  The  fibrous  and  fatty  tissues  later  proliferate  to  replace  the 
degenerated  muscle  fibers. 

Simple  atrophy  develops  most  frequently  after  non-use  (atrophy  of 
disuse)  of  a  muscle  or  group  of  muscles.  It  may  follow  cerebral  palsies 
or  accompany  as  a  reflex  atrophy  injuries  and  diseases  of  the  joints. 
In  simple  atrophy  the  electrical  irritability  of  the  muscle  is  reduced,  but 
there  is  no  reaction  of  degeneration. 

The  results  of  simple  nniscular  atrophy  are  a  decrease  in  the  size  of 
the  muscle,  complete  or  incomplete  loss  of  function,  and  contractures 
due  to  shortening  of  antagonistic  muscles  or  groups  of  muscles. 

Inactivity  and  Reflex  Muscular  Atrophy. — Inactivity  and  reflex  mus- 
cular atrophy  cannot  be  sharply  separated.  It  is  a  well-known  fact  that 
muscles  decrease  in  size  when  patients  are  b(^dridden  for  a  long  time. 
It  is  most  pronounced,  hoM^ever,  when  an  extremity  is  immobilized  in 
splints  or  a  pi aster-of -Paris  cast  for  a  long  period.  If  there  is  an 
injury  or  an  inflammation  of  the  articular  end  of  a  bone,  or  a  disease 
or  injury  of  a  joint,  a  pronounced  atrophy  of  the  muscles,  especially 
of  the  extensors,  more  rarely  of  other  muscles,  develops  in  one  or  two 
weeks.    Atrophy  of  the  deltoid,  triceps,  quadriceps  extensor,  and  gluteal 


DISEASE   OF    MUSCLES   AND   TILN'DONS  655 

muscles  follows  inflammations  and  injuries  of  the  shoulder,  elbow,  knee, 
and  hip  joints  respectively. 

The  so-called  arthritic  muscular  atrophy  is  not  entirely  due  to  in- 
activity, as  it  develops  rapidly  even  when  no  immobilizing  dressing  has 
been  applied,  and  it  rarely  occurs  in  hemiplegia,  and  when  it  does  it 
is  not  pronounced.  Paget,  Vulpian,  Charcot,  and  others  believe  that 
muscular  atrophy  associated  with  diseases  of  joints  is  of  a  reflex  nature. 
According  to  the  theory  advanced  by  them,  irritation  is  transmitted 
from  the  diseased  or  injured  part  along  the  sensory  nerves  to  the  cells 
in  the  anterior  horns  of  the  spinal  cord,  which  have  a  trophic  influence 
over  the  muscles  related  to  the  joint,  and  this  irritation  produces  a 
change  in  the  cells  resulting  in  atrophy  of  the  nuiscles.  Raymond, 
Deroche,  and  Hofl'a  have  been  able  to  prevent  this  atrophy,  after  pro- 
ducing an  arthritis  experimentally,  by  cutting  the  posterior  roots  of  the 
spinal  nerves,  interrupting  in  this  way  the  reflex  arc. 

Degenerative  atrophy  develops  in  muscles  after  injuries,  inflamma- 
tion, and  circulatory  disturbances;  during  the  course  of  or  following 
infectious  diseases  (especially  typhoid  and  tetanus,  more  rarely  recur- 
rent fever  and  general  pyogenic  infections)  ;  in  all  peripheral  paralyses 
following  injury  and  inflannnation  of  the  nerves ;  and  in  spinal  lesions 
in  which  the  integrity  of  the  anterior  horn  cells  is  destroyed.  In  the 
degenerative  atrophies  following  lesions  of  the  cells  of  the  anterior  horn 
or  of  the  peripheral  nerves  the  reaction  of  degeneration  will  be  present. 

^he  degenerating  muscle  becomes  shrunken  and  shortened,  and 
marked  functional  disturbances  follow  the  development  of  contractures. 

Ischaemic  Paralysis  and  Contractures. — ^Marked  interference  with  the 
flow  of  arterial  blood  is  the  most  dangerous  of  the  circulatory  disturb- 
ances.    The  most  usual  causes  are  injuries,  ligation,  embolism  or  throm- 


FiG.  243. — IscH.EMic  Muscular  Paralysis  and  Contracture  following  the  Use  of 
AN  Improperly  Applied  Plaster-of-Paris  Dressing. 

* 

bosis  of  one  of  the  larger  arteries,  when  a  collateral  circulation  is  not 
established ;  long-continued  action  of  great  degrees  of  cold ;  poorly  ap- 
plied, constricting  plaster-of-Paris  casts;  and  constriction  for  purposes 
of  artiflcial  ischaemia  maintained  for  more  than  two  or  three  hours. 


656       SURGICAL    DISEASES,    EXCLUDING    INFECTIONS   AND   TUMORS 

AVlien  the  circulation  is  seriously  interfered  with  the  muscles  become 
painful,  swollen,  of  a  boardlike  hardness,  and  no  longer  contract.  Pas- 
sive motion  is  painful  and  is  no  longer  free.  After  a  few  days  contrac- 
tures which  become  more  marked  as  the  involved  muscle  undergoes 
cicatricial  contraction  develop.  These  contractures  may  become  very 
pronounced  if  an  entire  group  of  nuiscles,  such  as  the  flexors  of  the  fin- 
gers and  hand,  degenerates.  The  contractures  are  less  marked,  and  im- 
provement may  follow  mechanical  treatment  if  a  considerable  number  of 
muscle  fibers  capable  of  regeneration  remain.  Von  Volkmann  was  the 
first  to  recognize  and  describe  isehamiic  palsies  and  contractures  (Leser). 
According  to  Ilildebrand,  the  view  held  up  to  the  present  time  that  the 
nerves  are  not  involved  in  this  form  of  palsy  is  false.  Not  infrequently 
sensory  disturbances  resulting  from  injuries  of  the  nerves  are  also 
present,  the  latter  being  injured  by  the  ischa^mia  or  by  the  pressure 
exerted  by  the  cicatricial  tissue  developing  in  the  nuiscles. 

Ischa-mic  nuiscular  paralysis  differs  from  paralysis  of  nervous  origin 
in  its  clinical  course  and  in  the  absence  of  the  reaction  of  degeneration. 

Course  and  Prognosis  of  Different  Forms  of  Atrophy. — The  course  and 
prognosis  of  the  different  forms  of  muscular  atrophy  depend  upon  the 
cause,  the  character,  and  the  degree  of  the  pathological  changes.  If  the 
cause  can  be  removed,  and  the  degenerative  changes  are  not  so  exten- 
sive as  to  render  regeneration  impossible,  restoration  of  function  may 
follow  massage,  active  and  passive  motion,  baths,  and,  in  paralyses  fol- 
lowing nerve  lesions,  electricity.  Contractures  which  demand  special 
treatment  may  develop  (vide  p.  703).  In  the  treatment  of  ischa^mic 
paralysis,  Ilildebrand  recommends  that  the  nerves  be  dissected  out  early 
from  the  shrinking,  contracting  muscles,  and  be  placed  beneath  the  fascia. 

(c)    THICKENING   AND   GANGLION  OF   THE   TENDONS 

Thickening  of  the  tendons  occurs  in  the  form  of  small  nodules  or 
fusiform  enlargements  upon  the  fiexors  of  the  fingers,  and  is  the  most 
frequent  cause  of  the  condition  known  as  trigger-finger.  When  the 
patient  attempts  to  open  his  hand,  the  finger  affected  remains  flexed 
when  the  others  are  extended,  and  when  the  affected  finger  is  extended 
with  the  other  hand  it  flies  open  with  a  spring  or  jerk.  The  finger 
affected  may  also  remain  extended  when  the  other  fingers  are  flexed, 
and  the  same  spring  or  jerk  occurs  when  it  is  flexed  with  the  other 
hand.  There  can  frequently  be  felt  during  these' movements  a  hard, 
nodular  thickening  of  the  tendon  which  interferes  with  the  free  move- 
ment of  the  latter  within  its  sheath.  When  the  tendon  sheath  becomes 
sufficiently  expanded  to  allow  this  enlargement  to  pass,  the  fingers  be- 
come flexed  or  extended  with  a  jerk. 


DISEASES   OF   THE  TENDON   SHEATHS   AND   BURS^  657 

When  the  tendon  has  been  exposed  for  the  relief  of  trigger-finger, 
the  antlior  has  often  fonnd  a  limited  fibrous  thiekeiiinii-  n])on  the  sur- 
face of  the  tendon,  or  a  small  round  nodule  resembling'  a  fil)roma  Avithin 
a  fusiform  enlargement;  once  a  small  eyst  (tendon  ganglion),  such  as 
has  been  described  by  Thorn  and  Franz. 

Frequently  small  exudations  of  blood  within  the  tendon  cause  similar 
changes  and  the  transitory  snapping  of  all  the  fingers  with  the  excep- 
tion of  the  thumb.  This  is  often  observed  after  long-continued  rowing, 
and  is  the  result  of  pressure  and  traction  upon  the  tendons.  It  often 
develops  on  the  left  hand  of  recruits,  and  is  due  to  the  pressure  of  the 
butt  of  the  rifle. 

Ganglia  of  the  tendons,  resembling  ganglia  developing  in  the  cap- 
sule of  the  joint  and  in  tendon  sheaths,  are  probably  of  traumatic  origin, 
and  are  to  be  regarded  as  degeneration  cysts.  In  rare  cases  they  have 
been  observed  in  the  tendon  of  the  peroneus  tertius  (Ilofmann),  in  that 
of  the  triceps  brachii  (Borchardt),  and  in  the  extensor  tendons  of  the 
index  finger  (JMorian).  They  are  found  most  frequently  in  the  tendons 
of  the  flexors  of  the  fingers  and  may  be  the  cause  of  trigger-finger. 

Literature. — Borchardt.  Ganglienbildung  in  cler  Sehne  des  M.  triceps  brachii. 
Arch.  f.  klin.  Cliir.,  Bd.  62,  1900,  p.  US.^Flatau.  Muskelatrophieu  nach  PVakturen, 
Luxationen  iind  arthritischen  Gelenkerkraiikungen.  Sammelreferat  mit  Lit.  Zentralbl. 
f.  d.  Grenzgeb.,  1902,  No.  8. — Franz.  Ueber  Ganglien  der  Holilliand.  Arch.  f.  klin. 
Chir.,  Bd.  70,  1903,  p.  973. — Hildebrand.  Ischamische  Muskellahmung.  Deutsche 
med.  Wochenschrift,  1905.  Yereinsbeilage,  p.  1577. — Hoffa.  Die  Pathogenese  der 
arthritischen  Muskelkrankungen.  Chir.-Kongr.  Verhandl.,  1892,  I,  p.  93. — Hojmann. 
ITeber  Ganglienbildung  in  der  Kontinuitat  der  Sehnen.  Zentralbl.  f.  Chir.,  1899,  p. 
1315. — Lcser.  Untersuchungen  iiber  ischamische  Muskellahmungen  und  Muskel- 
kontrakturen.  v.  Volkmanns  Samml.  klin.  Vortr.,  1884,  No.  249. — Lorenz.  Die 
Muskelerkrankungen.  Wien,  1898. — Morian.  Beitrag  zu  den  intratendinrisen  Gan- 
glien. Munch,  med.  Wochenschr.,  1900,  p.  1766.— Thorn.  Ueber  partielle  Zerreissung 
einer  Beugesehne  am  Vorderarm  mit  sekundarer  Bildung  einer  ganglionahnlichen 
Degenerationszyste.     Arch.  f.  klin.  Chir.,  Bd.  58,  1899,  p.  918. 


CHAPTER    III 

DISEASES   OP    THE   TENDON    SHEATHS   AND   BURS/E 

Dry  Synovitis. — Dry  synovitis  (synovitis  sicca),  the  counterpart  of 
dry  pleurisy  (pleuritis  sicca),  develops  in  tendon  sheaths  after  over- 
exertion and  laceration  of  the  tendons.  The  terms  tendovaginitis  and 
tenalgia  crepitans  have  been  applied  to  this  disease,  as  a  grating  and 
creaking  sensation  is  imparted  to  the  palpating  finger  whenever  the 
inflamed   tendon    moves.      This    sensation   is   caused   by   a   roughening 


658       SURGICAL   DISEASES,    EXCLUDING   INFECTIONS  AND  TUMORS 

due  to  the  fibrin  which  is  deposited  upon  both  visceral  and  parietal 
layers  of  the  synovial  membrane  secondary  to  a  small  serohemorrhagic 
exudate. 

The  other  symptoms  are  severe  pain  when  movements  are  made,  and 
the  development  of  a  long  swelling,  slightly  tender  to  pressure,  corre- 
sponding to  the  position  and  course  of  the  tendon.  The  tissues  sur- 
rounding the  tendon  also  become  swollen  and  infiltrated. 

A  dry  synovitis  subsides  in  a  short  time;  within  two  wrecks  even 
in  the  severest  cases.  As  the  disease  is  caused  by  strains  and  sprains 
received  during  work,  recurrences  are  common. 

The  extensor  tendons  of  the  thumbs  of  laundresses  are  frequently 
involved  as  a  result  of  the  wringing  of  clothes.  Not  infrequently  the 
extensor  tendons  of  blacksmiths,  locksmiths,  drummers,  and  piano  play- 
ers become  involved,  especially  when  the  work  is  so  heavy  or  practice 
is  continued  so  long  that  the  tendons  are  strained.  It  is  much  more 
apt  to  develop  in  novices  than  in  people  who  are  accustomed  to  their 
particular  lines  of  work.  The  tendons  of  the  peroneal  and  tibial  mus- 
cles are  atiPected  in  oarsmen.  Similar  lesions  develop  in  the  tendo 
Achillis  of  ballet  dancers,  although  this  tendon  has  no  synovial  sheath. 

The  diagnosis  is  easily  made.  The  position  and  form  of  the  swelling 
arouses  the  suspicion  of  the  experienced  surgeon  at  once.  The  peculiar 
creaking  and  grating  sensation  elicited  when  the  tendon  moves  to  and 
fro  makes  the  diagnosis  positive.  This  sensation  is  elicited  only  when 
certain  movements  are  made,  and  only  over  the  course  of  the  tendon ; 
therefore  it  can  easily  be  differentiated  from  the  crepitus  elicited  in  dis- 
eases of  the  joints  and  in  fractures. 

The  treatment  consists  of  the  application  of  a  felt  or  pasteboard 
splint  to  immobilize  the  tendon  involved.  The  pain  disappears  in  a 
short  time;  the  other  symptoms  in  a  few  days.  If  in  severe  cases  there 
is  still  some  crepitus  at  the  end  of  a  week,  mild  massage,  active  and  pas- 
sive motion  are  indicated.  Excessive  use  of  the  tendon  or  tendons  should 
bo  avoided  for  some  time. 

Serous  and  Serofibrinous  Tendovaginitis. — Serous  and  serofibrinous 
exudates  frequently  follow  hivmorrbages  into  the  tendon  sheaths,  asso- 
ciated with  fractui-es  and  dislocations.  Usually  they  sul)side  during  the 
treatment  of  the  fi-acture  or  dislocation. 

Chronic  hydrops  of  the  tendon  sheaths  is,  as  a  rule,  of  tuberculous 
origin   ( ri(]r  p.  442). 

Ganglia  of  Tendon  Sheaths. — (Ganglia  of  the  tendon  sheaths  are  not 
conimon.  'I'liey  ai'e  siiiiibir-  to  the  ganglia  which  d(>V(>lop  from  the  cap- 
sule of  the  wrist  joint,  but  usually  ai-e  sninller  tlian  tlu^se.  Usually  they 
are  situated  near  tlie  metaearpo-plialangc^al  joint  on  either  side  of  the 
sheaths  of  the  (lexor  tendons.     They  may  exert  pressure  upon  the  digi- 


DISEASES  OF  THE  TENDON   SHEATHS  AND  BURS^ 


659 


tal   nerves  sufficient  to  cause   a   severe  neuralgia.      The   neui'alj;ia  rap- 
idly disappears  after  the  cysts  are  extii-pated   (Witzelj. 

Urates  may  be  deposited  in  the  different  tendon  sheaths  and  hursaj 
in  gout.  Those  adjacent  to  the  joint  first  involved  are  nearly  always 
affected  {vide  p.  725). 

Hygroma. — The  hydrops  or  hygroma  is  the  most  common  form  of 
chronic  inflammation  of  bursa^.  An  hygroma  follows  the  incomplete 
absorption  of  exudations  of  blood  into  bursa?  and  long-continued  me- 
chanical irritation. 

The  contents  of  an  hygroma  are  in  the  beginning  thick  and  mucoid 
in  character,  later  they  become  more  serous,  or,  after  an  injury,  lifem- 
orrhagic.  The  Avails  of  the  hy- 
groma are  not  smooth  like  those 
of  an  acutely  inflamed  bursa  or 
of  one  into  which  blood  has  been 
extravasated.  They  are  thick- 
ened and  contain  many  recesses, 
masses,  and  bands  of  tissue  with 
wartlike  and  villous  outgrowths 
(Fig.  244).  Often  the  villous 
outgrowths  are  so  large  and  nu- 
merous that  they  fill  the  cavity 
of  the  bursa,  which  then  con- 
tains but  little  fluid,  while  the 
thicker  and  more  delicate  bands 
of  tissue  extend  from  one  to  the 
other  wall  of  the  sac.  Often  the  surfaces  of  these  villous  masses  and 
bands  are  covered  with  old  blood  clots,  which  may  have  become  calcified. 
Free  bodies,  occasionally  a  point  of  a  knife  or  a  bullet,  may  be  found  in 
the  hygroma.  When  these  foreign  bodies  are  found,  they  should  be 
regarded  as  the  cause  of  the  chronic  inflammation  which  resulted  in 
the  formation  of  the  hygroma. 

Chronic  inflammation,  such  as  leads  to  hyperplastic  changes  in  the 
joints,  does  not  account  entirely  for  the  changes  in  the  walls  of  the 
bursa  above  described,  although  it  and  the  subsecpient  organization  of 
the  fibrinous  deposits  certainly  play  an  important  part.  Even  in  a 
recent  hygroma  one  finds,  as  might  be  expected,  not  a  simple,  but  a 
multilocular  cavernous  cyst  (Schuchardt).  Some  of  the  masses  in  the 
wall  of  a  hygroma  and  of  the  free  bodies  are  formed  by  the  cicatricial 
contraction  of  the  inflamed  fatty  tissue  surrounding  the  bursa  (Graser). 
According  to  Langemak,  as  the  inflamed  fatty  tissue  contracts  it  is 
transformed  into  a  mass  of  collagenic  scar  tissue.  After  the  formation 
of  an  interstitial  substance  which  resembles  fibrin,  this  scar  tissue  lique- 


FiG.  244. — Hygi{cim\    111  Ks.K  Olkcrani. 


660       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND   TUMORS 


fies,  and  as  a  result  degeneration  cysts  form  in  the  wall  of  the  bursa 
and  in  the  tissues  surrounding  it.  These  cysts  eventually  rupture 
through  the  wall  of  the  bursa,  and  a  communication  is  established  with  it« 
interior.  This  accounts  for  the  formation  of  recesses  and  evaginations 
in  hygromas.  Hygromas  are  closely  related  pathologically  to  ganglia, 
which  are  also  formed  by  the  liquefaction  of  tissue  {vide  p.  731). 

In  the  majority  of  instances  an  hygroma  develops  as  a  painless  hemi- 
spherical swelling  with  a  smooth  surface,  covered  by  normal  or  slightly 
thickened  skin.     In  some  instances,  however,  the  bursa  enlarges  rapidly 

after  a  trauma  when  blood  is  poured  out 
into  its  cavity  and  the  swelling  does  not 
subside.  An  hygroma  may  become  as 
large  as  a  hen 's  egg  or  an  apple ;  in  rare 
cases  even  larger.  The  swelling,  sharply 
defined  externally,  fuses  below  with  the 
deeper  tissues  and  is  attached,  depending 
upon  its  position,  to  the  surface  of  a  bone 
or  tendon.  It  can  therefore  be  displaced 
but  little.  As  a  rule,  fluctuation  can  be 
elicited  when  the  sac  is  not  too  full.  Nodu- 
lar areas  can  frecpiently  be  palpated  in 
the  thickened  walls  of  an  old  hygroma. 
A  peculiar  grating  or  creaking  sensation 
can  be  elicited  upon  pres- 
sure, even  when  there  is 
little  fluid. 

j\Iost  Common  Posi- 
tions for  Hygromas.  — 
Hygromas  develop  upon 
those  parts  of  the  body 
where  a  bursa  is  normally 
present,  or  where  a  bony 
prominence  is  continu- 
ously exposed  to  pressure 
and  the  development  of  a  bursa  is  favored.  Hygromas  of  the  prepatellar 
and  olecranon  bursae  are  the  most  frequent,  for  these  burs^  are  not  only 
exposed  to  injuries,  but  also  to  mechanical  irritation  in  a  number  of  dif- 
ferent occupations — prepatellar  bursa  in  housemaids  and  scrub  women 
(housemaid's  knee),  olecranon  bursa  in  miners  (miner's  elbow). 

Hygromas  of  the  bursas  about  the  shoulder  and  hip  joints,  and  pop- 
liteal space,  follow  sprains  and  dislocations  of  the  joints.  Inflammation 
of  the  acromial  bursa  is  caused  by  pressure  (being  of  rather  frequent 
occurrence  in  hod  carriers).    The  largest  hygromas  developing  in  newly 


Fig.  245. — Hyouoma  Burs-is  Olecrani. 


DISEASES   OF   THE   BLOOD   AND   LYMPHATIC   VESSELS 


661 


formed  bursa?  are  found  on  the  outer  niaryin  of  a  clubfoot.  The  hy- 
gromas developing  in  other  varieties  of  bursts  are  usually  small,  the 
best-known  examples  being  the  hygro-  ._ 

ma  developing  over  the  head  of  the 
first  metatarsal  bone  in  hallux  valgus, 
and  over  fractures  in  which  there  is  a 
subcutaneous  angular  deformity. 

JIulflph  Hijyromas. — The  develop- 
ment of  nniltiple  hygromas  always  sug- 
gests some  infectious  cause  (gonorrhea, 
tuberculosis,  syphilis),  as  hygromas  of 
mechanical  origin  are  usually  single,  or 
the  corresponding  bursa  on  the  other 
side  is  the  only  other  one  involved. 
Deep-lying  hygromas  about  the  hip  or 
in  the  popliteal  space  may  resemble 
tumors  or  gravitation  abscesses,  and  it 
may  be  necessary  to  aspirate  the  swell- 
ing in  order  to  make  a  positive  diag- 
nosis. 

Treatment. — The  amount  of  thick- 
ening in  the  wall  of  the  bursa  deter- 
mines the  treatment  which  should  be 
instituted.  If  the  hygroma  is  recent  and  the  walls  are  not  thickened,  as- 
l)iration  of  its  contents,  followed  by  the  injection  of  iodin  or  carbolic  acid 
and  compression,  may  result  in  a  permanent  cure.  If  the  walls  of  the 
bursa  are  thickened  and  indurated,  complete  excision  will  probably  be 
necessary.    Complete  excision  is  also  to  be  preferred  if  a  fistula  is  present. 

Literature. — Grnser.  Ueber  die  sogenannte  Bursitis  proliferans.  ZentralbL  f. 
Chir.,  1902,  p.  46. — Heineke.  Die  Anatomie  und  Pathologic  der  Schleinil)eutel  iirid 
Sehnenscheiden.  Erlangen,  1868. — Langemak.  Die  Entstehung  der  Hygrome.  Arch, 
f.  klin.  Chir.,  Bd.  70,  1003,  p.  946. — Schuchardt.  Ueber  die  Entstehung  der  subkutanen 
Hygrome.  Chir.-Kongr.  Verhandl.,  1890,  II,  p.  1. — Witzel.  Ganglien  an  der  Greifseite 
der  Hand  als  Ursache  von  Neuralgien.     Zentralbl.  f.  Chir.,  1888,  p.  137. 


Fig.  246. — Hygroma  Burs.e 

PR.Er.\TELLARIS. 


CHAPTER    IV 

DISEASES   OP   THE   BT>OOD   AND   LYMPHATIC   VESSELS 


(a)  ARTERIOSCLEROSIS,  ATHEROSCLEROSIS 

ARTERiosciiEROSis  (clironic  deforming  endai-feritis,  atheroma  of  the 
arteries,  atherosclerosis  of  Marchand)  may  be  the  cause  of  a  number  of 
important  surgical  lesions. 


662       SURGxCAL    DISEASES,    EXCLUDING    INFECTIONS   AND   TUMORS 

The  entire  process,  which  is  chronic,  is  of  a  degenerative  nature.  It 
usually  begins  in  adult  life,  in  people  of  about  forty  years  of  age,  more 
rarely  in  young  people.  The  entire  or  greater  part  of  the  arterial  sys- 
tem may  be  involved  in  the  pathological  process.  Fatty  degeneration 
and  proliferation*  of  the  intima,  resulting  in  the  formation  of  foci  filled 
with  detritus,  ulceration,  fibrtms  indui'ation  (sclerosis),  and  calcification 
of  the  vessel  wall  go  hand  in  hand.  A  localized  form  characterized  by 
the  formation  of  small  flat  nodules,  which  nuiy  undergo  fatty  degenera- 
tion and  form  atheromatous  ulcers  (arteriosclerosis  circumscripta  or 
nodosa),  is  frequently  combined  with  a  diffuse  proliferation  of  the 
intima  (arteriosclerosis  diffusa),  which  leads  to  the  occlusion  of  the 
lumina  of  the  smaller  arteries  (endarteritis  obliterans).  Fibrous 
changes  also  occur  in  the  tunica  media  and  lime  salts  are  deposited  in 
its  muscular  fibers.  This  is  often  associated  with  the  formation  of 
nodules,  especially  in  the  arteries  of  the  lower  extremities.  The  cellular 
infiltration  and  thickening  of  the  tunica  adventitia  in  arteriosclerosis  is 
never  so  marked  as  in  the  arterial  changes  of  syphilitic  origin  (vide 
p.  505). 

The  arteries  affected  become  hard,  irregular,  slightly  tortuous,  and 
may  be  easily  palpated.  Upon  section  it  may  be  easily  seen  that  the 
lumina  of  the  arteries  are  greatly  reduced  in  size.     The  arteries  are 


Fig.  247. — Sci-euotic  Arteries  as  they  Appear  in  a  Roentgen-ray  Picture.  Male 
patient,  fifty-five  years  of  age,  suffering  with  dry  gangrene  of  the  distal  phalanx  of  index 
finger. 

often  so  hard  and  fragile  that  they  are  li  gated  with  difficulty.  When 
dissected  free  they  appear  as  yellowish  white,  irregular,  nodular  strands ; 
and  in  Roentgen-ray  pictures,  if  there  are  enough  lime  salts,  as  faint 
beady  shadows,  resembling  a  necklace  (vide  Fig.  247). 

Causes  of  Arteriosclerosis. — There  are  a  number  of  different  views 
concerning  the  eansc  of  ar'terioscl(>rosis.  It  may  be  due  to  nutritional 
(lisliirbadfcs  in  llic  intiina  resulting  from  injuiy  of  th(^  media  or  of  the 
elastic  elements  of  tlie  vessel  wall  (Mai'chaiid),  to  primaiy  inflammation 
of  the  vessel  wall  (Kiister),  or  to  a  weakening  of  the  media  with  com- 
pensatory })folil'<'i-a1i()n  of  the  intima  (Thoma). 


DISEASES  OF   THE   BLOOD   AND   LYMPHATIC    VESSELS  663 

The  principal  etioloi^ieal  factor  is  increased  intraarterial  pressure, 
which  may  be  continuous  or  intermittent  (JNlarchand).  There  are  a 
number  of  general  and  local  predisposing  causes,  such  as  diseases  of 
the  central  nervous  system  and  peripheral  nerves  (tabes,  syringomyelia, 
neuritis)  ;  the  action  of  a  number  of  diiferent  poisons  (alcohol,  tobacco, 
ergot,  lead,  mercury,  phosphorus)  ;  infectious  diseases  of  all  kinds,  of 
the  chronic  type,  especially  syphilis  and  leprosy;  constitutional  diseases 
(gout,  diabetes)  ;  excessive  physical  effort  (with  acute  dilatation  of  the 
arteries)  ;  thermal  influences  (action  of  mild  degrees  of  cold)  (Zoege 
von  ]\Ianteuffel). 

Results  of  Arteriosclerosis. — The  results  of  arteriosclerosis  are:  (1) 
Disturbanct's  of  the  general  circulation  and  the  function  of  the  different 
viscera,  resulting  from  the  lessened  distensibility  of  the  arteries  and 
narrowing  of  the  lumina  of  the  vessels.  The  interference  Avith  the  cir- 
culation is  most  marked  when  the  veins  are  also  diseased.  (2)  Occlu- 
sion of  the  vessels  by  proliferation  of  the  intima,  thrombosis,  or  em- 
bolism, the  embolus  arising  in  an  atheromatous  ulcer  in  a  vessel  nearer 
the  heart.  If  the  heart  action  is  bad  and  the  vessels  entering  into  the 
collateral  circulation  are  diseased,  gangrene  of  the  tissues  supplied  by 
the  artery  frequently  follows  its  occlusion  (senile  gangrene  of  the  toes, 
embolic  gangrene  of  the  extremities).  (3)  Rupture  of  the  diseased 
vessel,  which  is  most  frequent  in  the  cerebral  arteries,  causing  apoplexy. 
(4)   Aneurysm.      (5)    Thrombosis. 

LiTEKATURE. — Fr.  Fischcr.  Die  Erkrankungen  tier  Lymphgefiisse,  Lymphdriisen 
und  Blutgefasse.  Deutsche  Chir.,  1901. — Jores.  Wesen  und  Entwickkmg  der  Arterio- 
sklerose.  Wiesbaden,  1903. — Marchand.  Arterien.  Eulenburgs  Realenzyklopiidie, 
1894; — -Die  Arteriosklerose  (Atherosklerose).  21.  Kongress  f.  innere  Medizin.  Leipzig, 
1904.  Verhandk,  p.  23. — Romberg.  I'eber  Arteriosklerose.  Ibid.,  p.  60. — v. 
Schr otter.  Erkrankungen  der  Gefiisse.  Nothnagels  spez.  Path.  u.  Ther.,  Bd.  15,  Part 
Z.—Thoma.  Die  diffuse  Arteriosklerose.  Virchows  Arch.,  Bd.  104,  1886,  p.  209. — 
Zoege  V.  Manteuffel.     Arteriosklerose.     Kochers  Enzyklopiidie,  1901. 

(b)  ANEURYSMS 

By  aneurysm  (from  the  Greek  drcwpwetr,  meaning  to  widen)  is 
understood  a  pathological  dilatation  of  an  artery.  Aneurysms  occur  in 
two  principal  forms,  the  simple  or  arterial  and  the  arteriovenous.  In 
the  former  there  is  a  dilatation  of  the  arterial  wall;  in  the  latter  a 
communication  between  an  artery  and  a  vein,  with  or  without  an  inter- 
vening sac.  Because  of  the  similarity  of  clinical  symptoms  the  pul- 
sating or  arterial  hcematoma  must  be  classified  with  aneurysms,  even 
if  the  sac  is  not  formed  by  the  wall  of  an  artery,  but  by  blood  which 
has  been  poured  out  into  the  tissues  and  has  coagulated.  A  true  is  dis- 
tinguished from  a  false  aneurysm.     In  the  former  all  the  tunics  of  the 


664      SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND  TUMORS 

vessel  are  present,  while  in  the  latter  the  sac  of  the  aneurysm  contains 
little  or  none  of  the  original  tunics  of  the  vessel  wall.  [This  distinction, 
as  Cohnheim  has  said,  is  artificial  and  not  based  upon  sound  pathological 
principles.] 

The  form  of  an  aneurysm  differs,  depending  upon  whether  the  entire 
circumference  of  an  artery  or  only  a  portion  of  it  is  involved.  If  only 
a  portion  of  the  arterial  wall  becomes  dilated  a  saccular  aneurysm,  if 
the  entire  circumference,  a  cylindrical  (spindle-shaped,  fusiform)  or 
cirsoid  aneurysm  (or  better  angioma  racemosum)  develops. 

A  number  of  different  varieties  of  true  arterial  aneurysms  have 
been  described,  the  descriptions  being  based  upon  the  mode  of  devel- 
opment. 

Congenital  Aneurysm. — In  rare  eases  congenital  aneurysms  of  the 
abdominal  aorta  (Phaenomenow),  of  the  ductus  Botalli  (Thoma),  and 
multiple  aneurysms  of  the  sinall  arteries,  due  to  congenital  defects  in 
the  elastic  elements  of  the  walls  of  the  vessels,  have  been  observed. 

Spontaneous  Aneurysm. — Two  different  forms  of  spontaneous  aneu- 
rysm have  been  described,  depending  upon  the  way  in  which  they  are 
produced:  aneurysm  by  distention  (Thoma),  aneurysm  hy  rupture  (Ep- 
pinger).  In  the  former  the  arteriosclerotic,  inflamed,  or  healing  arterial 
wall  is  stretched,  and  the  least  resistant  portion  gives  way  and  becomes 
dilated  or  evaginated;  in  the  latter  the  elastic  elements  of  the  media 
and  one  of  the  other  tunics  of  the  vessel  wall  are  ruptured  by  a  sudden 
rise  in  blood  pressure,  the  result  of  physical  effort  or  mental  excite- 
ment. The  aneurysm  by  distention  is  diffuse,  sometimes  associated  with 
evaginations,  and  occurs  as  the  fusiform  or  cylindrical  aneurysm.  An 
aneurysm  by  rupture  is,  as  a  rule,  a  saccular  aneurysm.  Spontaneous 
aneurysms  develop  most  frecpiently  in  arteries  surrounded  by  loose 
connective  tissues,  which  afford  but  little  support  to  the  arterial  wall. 

Aneurysm  by  Erosion. — If  the  wall  of  an  artery  within  an  acute  or 
tuberculous  abscess  becomes  inflamed  and  necrotic,  an  aneurysm  may 
develop  Avithin  the  necrotic  area  if  immediate  ruj^ture  does  not  occur. 
In  these  cases  the  intima  often  projects  through  the  defect  in  the  media 
and  adventitia,  and  sometimes  these  aneurysms  are  spoken  of  as  Jiernial 
an(  urysuis. 

Embolic  Aneurysms. — An  embolic  aneurysm  develops  after  the  in- 
liiiia  has  been  injufed  ])y  a  hard,  sharj)  em])()lus  which  has  been  set  free 
from  a  hard,  calcareous  pla(|ue  in  an  ai'tei'iosclerotic  artery,  or  after 
infection  of  the  intima  following  lodgment  of  an  embolus  containing 
bacteria  (mycotic  aneurysm) . 

True  Traumatic  Aneurysm. — The  dilatation  occurs  in  that  part  of  the 
artery  the  walls  of  which  have  been  crushed  or  lacerated,  but  not  com- 
j)letely  destroyed. 


DISEASES   OF   THE   BLOOD   AND   LYMPHATIC   VESSELS  C65 

Dissecting  Aneurysm. — The  dissecting  aneurysm  develops  when  the 
intinia  and  media  have  been  ruptured  and  the  adventitia  remains  intact. 
["  The  blood  spreads  between  the  layers  of  the  vessel  wall,  stripping 
up  the  inner  from  the  outer  half,  the  line  of  cleavage  being  within  the 
middle  coat,  half  going  with  the  adventitia,  half  with  the  intima." — 
Rose  and  Carless,  "  Manual  of  Surgery,"  p.  306.]  If  the  blood  spreads 
around  the  entire  circumference  of  the  artery  a  diffuse  cylindrical  aneu- 
rysm develops ;  if  it  is  confined  to  one  porticm  of  the  arterial  wall,  a 
saccular  aneurysm  forms.  The  extravasated  blood  either  coagulates  in 
the  vessel  wall  or  ruptures  through  the  adventitia. 

A  false  traumatic  aneurysm  develops  as  a  saccular  aneurysm  from  a 
pulsating  or  arterial  ha'inatoma  which  follows  a  wound  (punctured,  con- 
tused, gunshot,  or  lacerated)  of  the  vessel  wall.  The  connective  tissue 
surrounding  the  ha?matoma  becomes  thickened  to  form  the  sac  of  the 
aneurysm  which  contains  none  of  the  tunics  of  the  vessel  wall.  The 
blood  enclosed  within  the  thickened  connective  tissue  coagulates  and  sur- 
rounds a  cavity  into  which  the  blood  passing  out  of  the  opening  in  the 
vessel  wall  flows.  The  arterial  wall  proper  is  not  dilated.  This  variety 
of  aneurysm  may  develop  about  the  end  of  an  artery  in  an  amputation 
stump.  The  small  projectiles  used  in  modern  rifles  produce  traumatic 
aneurysms  more  frequently  than  the  larger  ones  formerly  used  (vide 
Gunshot  Wounds). 

Age  at  Which  Aneurysms  Most  Commonly  Develop — Vessels  Most 
Commonly  Involved. — The  simple  arterial  aneurysm  is  about  twice  as 
frequent  in  the  male  as  in  the  female,  and  develops  most  frequently  be- 
tween the  thirtieth  and  fiftieth  years  of  life.  Aneurysms  are  most  com- 
mon in  the  thoracic  aorta;  then  in  the  popliteal  and  femoral  arteries; 
appearing  next  in  order  of  frequency  in  abdominal  aorta,  the  sub- 
clavian, innominate,  axillary,  iliac,  visceral,  cerebral,  and  pulmonary 
arteries  (Crisp).  If  the  small  aneurysms  are  considered,  the  arteries 
of  the  lungs  and  brain  are  most  frequently  involved  (Orth). 

Character  of  Aneurysmal  Sac. — The  sac  of  a  true  aneurysm  has  a  thin 
wall,  the  tunics  of  which  are  altered  by  the  original  disease  or  by  the 
scar  in  the  vessel  wall.  In  the  dissecting  aneurysm  the  tunics  of  the 
vessel  wall  are  separated  from  each  other  by  blood,  while  the  small  sac 
of  the  hernial  aneurysm  is  composed  of  endothelium  alone.  The  sac 
of  an  aneurysm  may  be  thickened  by  inflammatory  processes,  and  may 
become  closely  adherent  to  surrounding  tissues. 

The  sac  of  a  false  aneurysm  consists  of  d(>nse  connective  tissue.  It 
is  adherent  to  the  surrounding  tissues  and  has  no  endothelial  lining. 
Large  false  aneurysms  contain  stratified  layers  of  blood  clot  which 
strengthen  the  wall  of  the  sac  and  protect  it  for  a  long  time  against 
rupture.  These  clots  may,  however,  narrow  and  occlude  the  arteries 
43 


666      SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 


which  anastomose  and  provide  for  a  collateral 
circulation    or   project   into   the   lumen   of   the 

artery     and     be     the 
source  of  emboli. 

Size  of  Aneurysms. 
— The  size  of  an  an- 
eurysm varies,  de- 
pending upon  the 
caliber  of  the  vessel 
involved.     The  sac  of 

.f  an     aortic     aneurysm 

may  become  as  large 
as  a  fist. 

Enlargement  of 
an  Aneurysm.  —  The 
growth  of  an  aneu- 
rysm is  slow,  except 
in  the  embolic  or  my- 
cotic variety,  and  is 
often  retarded  or  in- 
terrupted by  throm- 
bus formation  and 
inflammatory  thick- 
ening of  the  sac. 

Symptoms. — In  the 
beginning  the  symp- 
toms are  not  distinct. 
Even  in  a  false  aneu- 
rysm, when  blood  is 
poured  out  into  the 
tissues,  the  symptoms 
may  be  obscure  or  in- 
significant at  first,  as 
the  luvmatoma  may 
be      deeply      situated 


Y\n.  248. — A,  Fusiform  Aneurysm  of  the  Popi.itead  Artery  Developing  in  a  Male 
Patient  Fifty-nine  Years  of  Age.  The  thiRh  was  amputatc.l  above  the  knee  because 
of  gangrene  of  the  foot,  c,  Advanced  arteriosclerosis;  g,  small  saccular  evaginations 
in  the  posterior  tibial  artery.  B,  Longitudinal  Section  of  the  Same  Prepara- 
tion. /,  Thick,  laminated  thrombus  in  the  popliteal  aneurysm.  The  thrombus  extends 
into  the  posterior  tibial  artery  (c)  down  to  the  origin  of  the  peroneal  artery  {h),  the 
lumen  of  which  is  greatly  narrowed.  The  posterior  (c)  and  anterior  tibial  (a)  arte- 
ries are  closed  by  thrombi.  Tlie  peroneal  artery  {V)  is  closed  by  endarteritis,  (d)  Cal- 
cified plaque. 


DISEASES   OF   THE   BLOOD   AND   LYMPHATIC   VESSELS  667 

and  covered  by  resistant  tissues.  The  symptoms  first  become  distinct 
and  pronounced  when  a  visible  and  palpable  tumor  develops,  or  when 
the  tumor  exerts  pressure  upon  important  structures.  Pulsation  may 
be  seen  in  the  round,  oval,  rarely  sharply  defined  tumor,  if  it  is  su- 
perficial. The  pulsation  is  expansile  in  character — i.  e.,  the  entire 
tumor  increases  in  size  with  each  systole  and  evenly  in  all  directions, 
so  that  if  the  tumor  is  lightly  grasped  in  any  position  the  fingers 
will  be  separated.  Pulsation  may  be  transmitted  to  a  tumor  or  ab- 
scess lying  near  or  upon  an  artery.  This  pulsation,  however,  is  never 
expansile,  the  tumor  or  abscess  being  merely  lifted  with  each  beat  of 
the  artery  and  not  expanding  evenly  in  all  directions.  Expansile  pul- 
sation is  therefore  of  great  diagnostic  importance.  There  is  felt  upon 
palpation  of  an  aneurysm  a  soft  thrill  or  fremitus,  there  is  heard  upon 
AUSCULTATION,  whcn  the  stethoscope  is  held  over  the  tumor,  a  bloiv- 
ing,  buzzing  bruit,  which  is  synchronous  with  systole,  but  may  also 
be  heard  in  diastole.  The  latter  is  produced  by  whirls  in  the  blood 
current,  formed  \Ahen  the  stream  entering  and  leaving  the  sac  meet. 
The  tumor  may  disappear  completely,  or  almost  completely,  when  pres- 
sure is  made  vipon  it,  to  reappear  when  the  pressure  is  released.  The 
expansile  pulsation  disappears  when  pressure  is  made  upon  the  artery 
proximal  to  the  tumor.  Pressure  upon  the  vessel  distal  to  the  aneurysm 
causes  the  latter  to  enlarge. 

All  these  symptoms  may  be  indistinct  or  absent  if  there  are  thick 
layers  of  blood  clot  within  the  sac. 

The  pulse  on  the  diseased  side  distal  to  the  aneurysm  is  weaker  than 
on  the  healthy  side  and  is  slightly  delayed,  and  the  apex  of  the  puLse 
wave  obtained  in  a  sphygmographic  tracing  is  lower  and  more  rounded. 

Pressure  Symptoms. — Pressure  upon  adjacent  nerves  frequently  gives 
rise  to  severe  and  distressing  symptoms.  Unpleasant  sensations  and  pain 
at  the  beginning  increase  to  severe  neuralgia  as  the  pressure  increases. 
Eventually  sensory  disturbances  and  paralyses  develop.  Pressure  upon 
adjacent  veins  is  indicated  by  passive  hypenvmia,  distention  of  the  sub- 
cutaneous veins  and  oedema.  The  compressed  vein  may  be  completely 
closed  by  a  thrombus. 

All  these  symptoms  increase  as  the  aneurysm  enlarges.  The  same 
symptoms  (especially  sensory  disturbances,  numbness,  formication,  pain) 
frequently  develop  immediately  after  the  injury  of  the  artery  in  trau- 
matic aneurysms,  and  are  caused  by  the  pressure  exerted  by  the  hfema- 
toma.  They  disappear  as  the  wound  heals,  but  return  after  a  number 
of  weeks,  as  the  sac  forms  and  increases  in  size. 

Clinical  Course. — Spontaneous  cure  of  an  aneurysm  by  filling  of  the 
sac  with  a  thrombus  or  thrombosis  of  the  artery  proximal  and  distal  to 
the  opening  communicating  with  the  sac  is  rare,  and  occurs  only  in  the 


668       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND  TUMORS 

smaller  aneurysms.  As  a  rule  an  aneurysm,  excepting  the  mycotio 
variety,  undergoes  a  continued  growth,  gradually  enlarging  until  it 
ruptures.  A  bone  adjacent  to  an  aneurysm  may  be  gradually  worn 
away  by  the  pulse  beat,  as  a  stone  is  worn  away  by  water  drops. 
The  bone  undergoes  pressure  atrophy.  An  aneurysm  of  the  thoracic 
aorta,  if  it  grows  forward,  gradually  destroys  the  sternum  and  ribs  and 
reaches  the  skin.  If  it  grows  posteriorly,  it  destroys  the  vertebrae  and 
may  eventually  exert  pressure  upon  the  spinal  cord  or  nerves  if  the 
sac  does  not  rii])ture  or  the  patient  does  not  die  of  some  intercurrent 
infection.  The  skin  covering  an  aneurysm  becomes  more  and  more 
tense,  and  finally  necrotic,  so  that  eventually  the  sac  of  the  aneurysm 
becomes  exposed.  It  may  then  rupture  externally  and  cause  death. 
If  before  rupture  the  poorly  nourished  skin  becomes  inflamed,  a  sub- 
cutaneous phlegmon  may  develop.  Rupture  of  the  sac  occurs  at  the 
point  where  the  blood  stream  exerts  the  greatest  pressure ;  that  is,  where 
the  deposition  of  layers  of  blood  clot  is  prevented.  Rupture  into  the 
pericardial,  pleural,  and  peritoneal  cavities  is  as  surely  fatal  as  external 
rupture  and  soon  causes  death,  the  symptoms  being  those  of  internal 
haemorrhage.  The  rupture  of  a  deep  aneurysm  in  an  extremity  is  indi- 
cated by  the  rapid  development  of  a  large  swelling  which  soon  ruptures 
externally,  as  the  tissues  covering  it  soon  become  necrotic  as  a  result  of 
the  pressure  exerted  upon  them.  A  ha^matoma  of  the  neck,  resulting 
from  rupture  of  an  aneurysm,  may  cause  sut^'ocation.  The  rupture  of 
an  aneurysm  into  a  vein  produces  the  secondary  form  of  arteriovenous 
aneurysm. 

Complications. — Complications  may  be  caused  by  separation  of  par- 
ticles of  a  thrombus  and  embolic  closure  of  the  peripheral  vessels  with 
subsequent  gangrene.  Gangrene  is  more  apt  to  develop  when  the  vessels 
entering  into  the  collateral  circulation  are  closed  by  thrombi  or  are 
obliterated  by  arteriosclerosis. 

ARTERIOVENOUS   ANEURYSM 

There  are  three  varieties  of  arteriovenous  aneurysm  (Hunter's  aneu- 
rysm by  anastomosis,  1784)    (vide  Fig.  249). 

The  arteriovenous  aneurysm  with  a  venous  sac,  the  so-called  varix 
aneurysmaticus  (Scarpa),  develops  most  frequently  after  the  simul- 
taneous injury  of  the  artery  and  vein  at  corresponding  points.  After 
agglutination  of  the  openings  in  the  vessels  the  arterial  stream  passes 
through  the  opening  in  the  vein  (arterioA^enous  fistula)  and  causes  a 
dilatation  of  the  wall  of  tlic  v<'in  opposite  the  opening,  resulting  in  the 
formation  of  a  vaiix.  The  s))oiitan('ous  develoj^meut  of  a  varix  aneu- 
rysmaticus is  i-nc.  In  llie  ciises  in  whicli  such  an- aneurysm  has  devel- 
oped   spontaneously   the    calcified    arterial    wall   has   probably    exerted 


DISEASES   OF   THE    BLOOD   AND    LYMPHATIC    VESSELS 


G69 


])r('ssure  npon  the  vein,  and  later  an  allu'i'oiiialoiis  ulci'i*  has  extended 
from  the  artery  throuiih  the  vein  wall. 

The  varix  usually  has  very  thin  walls  aiul  can  ]h'  easily  shelled  out 
from  the  surrounding  tissues. 

The  arteriovenous  aneurysm  with  a  false  sac,  the  so-called  aneuryama 
varicosiun.  (Scarpa),  likewise  develops  after  simultaneous  injury  of  an 
artery   and    vein   at   corresponding   points.      In    this   form,    however,    a 


A    V          A 

V 

Uf 

\^ 

\                             \ 

I 

V 


V 


(U 


M 


la 


16 


Fig.  249o. — The  Three  Principal  Forms  of  Arteriovenous  Axextrysm.  1.  Arteriovenous 
fistula  (a).  Arteriovenous  aneurysm  with  venous  sac,  Varix  aneurysmaticus  {h).  2.  Ar- 
teriovenous aneurysm  witli  false  intermediate  sac,  Aneurj'sma  varicosum.  3.  Arterio- 
venous aneurysm  with  arterial  sac,  secondary  arteriovenous  aneurj-sm. 


V 


V 


b  d 


V 


A 


iX 


V 


A      V 


^ 


St 


n 


A 


G  lb 


1  2a  26  3 

Flo.  2496. — Special  Forms.  1.  Arteriovenous  aneurysm  with  false  sac  and  varix  on  outer 
siile  of  the  vein.  Single  injury  of  the  artery,  double  injury  of  the  vein.  2.  Arterio- 
venous aneurj^sm  with  direct  communication  in  (a)  and  with  a  false  intermediate  sac 
in  (6)  and  with  a  false  arterial  aneurysm.  (Single  injury  of  vein,  double  injury  of  artery.) 
3.  Arteriovenous  fistula,  following  double  injuries  of  both  vessels.  The  sacs  lie  opposite 
each  other. 

communication  is  not  estahli.shed  directly,  as  the  vein  and  artery  are 
at  first  separated  by  a  blood  clot.  Both  the  artery  and  vein  connnuni- 
eate  with  the  false,  or,  according  to  its  position,  intermediary  sac,  which 
is  formed  from  the  blood  clot.  The  wall  of  the  sac  consists  of  the  re- 
mains of  the  ha^'matoma  and  thickened  connective  tissue.  It  is  therefore 
finnly  attached  to  the  surrounding  tissues  and  can  be  separated  with 
difficulty  from  nerves,  muscles,  etc.  ^Sn  aneurysm  of  this  kind  may 
develop  at  the  ends  of  arteries  and  veins  in  an  amputation  stump. 

The  arteriovenous  aneurysm  with  an  arterial  sac  sliould  ju'obably  be 
classified  as  a  varicose  aneurysm.     It  is  rare,  and  develoj)s  when  a  true 


670       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND   TUMORS 

aneurysm  erodes  the  wall  of  a  vein  and  rnptui-es  into  it  (secondary 
arteriovenous  aneurysm) . 

Different  special  forms  of  arteriovenous  aneurysm  may  develop  if, 
in  addition  to  perforation  of  corresponding  parts  of  the  wails  of  the 
artery  and  vein,  one  or  both  vessels  perforate  at  another  point.  Then 
the  wall  of  the  vein  opposite  the  point  of  conununication  with  the  true 
or  false  sac  may  develop  a  varix,  the  artery  may  develop  a  false  aneu- 
rysm, or  the  varix  and  aneurysm  may  be  combined  in  the  same  case 
{vide  Fig.  249). 

Most  Common  Causes  of  Arteriovenous  Aneurysms. — Punctured 
wounds  with  sharp  instruments  (aspirating  needle),  weapons,  or  objects 
(fragment  of  glass)  are  the  principal  causes  of  arteriovenous  aneurysm. 
["  According  to  Bramann,  of  159  cases  of  arteriovenous  aneurysm,  108 
were  due  to  an  injury,  56  following  phlebotomy,  29  gunshot  wounds,  5 
contusions  which  caused  no  external  wound,  and  9  were  spontaneous. 
In  only  four  instances  was  an  arteriovenous  aneurysm  congenital." — 
Tillmanns'  "  Text-book  of  Surgery,"  Vol.  I,  p.  534.] 

The  conditions  usually  necessary  for  the  production  of  this  form  of 
aneurysm  are  wounds  of  the  vessel  walls  lying  opposite  each  other,  long 
and  narrow  punctured  or  gunshot  wounds  with  small  points  of  entrance 
and  exit,  and  repair  without  inflammation  (von  Bergmann).  In  incised 
and  contused  wounds  rapid  agglutination  of  the  edges  of  the  wound  is 
required.  If  the  tunics  of  the  vessel  are  not  completely  divided,  the 
tissue  at  the  point  of  injury  must  first  become  necrotic  before  a  com- 
nmnication  can  be  establislied  between  the  vein  and  artery.  A  varicose 
aneurysm  may  follow  a  contusion  even  when  there  is  no  internal  wound, 
as  the  contused  areas  in  the  walls  of  the  vessels  agglutinate,  and  when 
ne(u-osis  occurs  an  arteriovenous  fistula  develops.  This  happened  in  five 
of  the  cases  collected  by  von  Bramann. 

Order  of  Frequency  in  which  Vessels  are  Involved. — According  to  the 
statistics  of  von  Bramann  and  Delbet,  the  vessels  are  involved  in  arterio- 
venous aneurysms  in  the  following  order  of  f reciuency :  brachial,  fem- 
oral, popliteal,  cai'otiti,  ai-teries  of  the  head,  especially  the  temporal, 
subclavian,  and  axillaiy.  This  form  of  aneurysm  may  also  develop 
spontaneously  in  the  abdominal  and  thoracic  aorta.  An  arteriovenous 
aneurysm  may  develop  after  injury  of  the  internal  carotid  artery  in 
the  cavernons  sinns. 

Symptoms. — The  symptoms  of  arteriovenous  differ  from  those  of  a 
simj)l('  aneurysm,  as  a  part  of  the  arterial  blood  is  poured  into  the  vein. 
Eddies  and  w hills  in  llie  blood  stream,  ])ulsation  of  the  veins,  and  stasis 
with  snl»se(|nent  dilatalion  of  llie  veins  are  found  in  this  form  of 
aneurysm.  Compressibilily  and  expansile  pidsation  of  the  tumor  are 
the  only  symptoms  common  1o  llie  two  forms. 


DISEASES   OF   THE   BLOOD   AND    LYMPHATIC    VESSELS  671 

The  eddies  and  whirls  in  the  blood  stream  produce  a  loud  wliistling 
bruit,  which  indicates  that  a  connnunication  has  been  established  be- 
tween the  artery  and  vein.  This  bruit,  which  is  often  present  immedi- 
ately after  the  injury,  is  most  distinct  at  the  point  of  comnuniication 
between  the  vessels,  but  may  be  heard  for  some  distance  proximalward 
and  distalwai'd  to  it.  It  diCfi'i's  i'l-oin  the  bruit  heard  in  an  arterial 
aneurysm  in  that  it  is  continuous  and  merely  increased  in  intensity 
during'  systole,  for  the  arterial  pressure  is  so  much  greater  than  the 
venoiLS  that  the  blood  enters  the  vein  continuously,  and  the  rate  and 
force  with  which  it  enters  is  merely  increased  during  systole.  It  is 
important  to  note  that  this  bruit  is  transmitted  along  the  veins  toward 
the  heart.  The  peripheral  transmission  is  less  important,  as  this  is 
occasionally  noted  in  simi)le  aneurysm.  The  whirls  and  eddies  also 
transmit  a  shock  to  the  vessel  wall  and  the  surrounding  tissue  which 
is  most  distinct  over  the  points  of  communication  between  vessels, 
and  weaker  on  either  side.  The  shock  imparts  to  the  palpating  hand 
the  impression  of  a  trembling  motion  or  a  soft  thrill  (von  Bramann, 
Franz), 

The  pulsation  is  not  limited  to  the  aneurysmal  sac,  but  extends 
proximalward  and  distalward  along  the  vein.  Both  dilate  simultane- 
ously, and  the  pulsation  is  more  marked  in  the  aneurysmal  varix,  in 
which  there  is  no  intervening  sac,  than  in  the  varicose  aneurysm,  in 
which  there  is  one.  This  pulsation  is  transmitted  to  the  subcutaneous 
veins  only  when  there  is  an  extensive  communication  with  the  deeper 
veins,  as  in  the  arm.  If  pres,sure  is  made  upon  the  artery  proximal  to 
the  aneurysm  the  pulsation,  bruit,  and  thrills  disappear.  If  it  is  pos- 
sible to  press  the  wall  of  the  sac  against  a  bone  so  that  only  the  point 
of  communication  is  closed,  the  pulse,  which  was  formerly  delayed  and 
small,  becomes  full  and  strong  (von  Bramann). 

Stasis  occurs  in  the  radicles  of  the  diseased  veins,  as  the  return 
flow  is  interfered  with.  In  the  beginning  there  is  merely  an  oedema 
and  a  filling  of  the  subcutaneous  veins.  Later  the  skin  becomes  bluish 
red  in  color,  the  subcutaneous  tissue  becomes  infiltrated  and  indurated, 
and  elephantiasis  develops.  The  results  are  nutritional  disturbances 
which  are  indicated  by  numbness,  itching,  a  tendency  to  eczema  and 
ulcer  formation,  muscular  atrophy,  and  complete  loss  of  fimetion.  The 
nutritional  disturbances  rarely  end  in  gangrene.  As  severe  nervous 
symptoms  may  occur  in  arteriovenous  as  in  arterial  aneurysm,  for  the 
sac  may  exert  pressure  upon  nerves  which  may  also  have  been  wounded 
at  the  time  the  vessels  were  injured.  The  severity  of  these  symptoms 
depends  upon  the  situation  of  the  aneurysm.  They  are  most  marked  in 
aneurysms  of  the  neck  and  legs,  least  so  in  aneurysms  of  the  arm  and 
head. 


672       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND  TUMORS 


Clinical  Course  and  Results.— An  arteriovenous  aneurysm  should  al- 
ways be  regarded  as  serious  (von  Bramann).  There  is  no  possibility 
of  spontaneous  repair,  in  spite  of  the  fact  that  the  sac  may  remain 
unaltered  for  years.  The  aneurysm  may  begin  to  grow  rapidly  at  any 
time.  The  rapid  growth  may  be  spontaneous  or  the  result  of  some  exter- 
nal influence.  Rupture  of  the  sac,  associated  with  the  symptoms  already 
described  in  discussing  arterial  aneurysm,  may  occur  at  any  time.  The 
lesions  resulting  from  the  nutritional  disturbances  may  become  infected 
and  progressive  suppurative  inflannnation  may  develop. 

Diag^nosis. — The  diagnosis  of  arterial  and  arteriovenous  aneurysms, 
which  may  be  distinguished  from  each  other  if  the  symptoms  are  closely 
observed,  is  not  difficult  when  the  symptoms  are  pronounced,  especially  if 
they  develop  immediately  after  injury  or  at  the  site  of  a  former  injury. 
In  differentiating  betAveen  an  aneurysmal  varix  and  a  varicose  aneurysm, 

it  should  always  be  remembered 
that  the  changes  in  the  venous  sys- 
tem are  always  more  marked  when 
there  is  a  direct  communication  be- 
tween the  artery  and  vein  than 
when  there  is  an  intervening  sac. 
Besides,  the  palpable  varix  is  softer 
and  more  easily  compressible  than 
is  the  false  sac  of  the  varicose  aneu- 
rysm. So  long  as  an  aneurysm 
of  the  thoracic  aorta  is  confined 
to  the  thoracic  cavity,  the  diag- 
nosis must  be  based  upon  the 
subjective  sj^mptoms  and  the 
findings  revealed  by  percussion,  aus- 
eultaticm,  and  the  X-ray.  When 
a  thoracic  aneurysm  has  eroded 
llie  ribs  and  appears  beneath  the 
skin,  the  latter  may  become  in- 
flamed, and  then  a  diagnosis  of  an 
acute  or  chronic  abscess  is  soiiie- 
tinies  made.  This  same  mistake  is 
also  made  in  aneurysms  in  other 
parts,  Avhen  the  skin  covering  them 
l)ecomes  inflamed. 

The  symptoms  of  an  arterial 
niieurysm  developing  spontaneously 
may  be  very  indefinite,  Foi-  if  snuill  llicre  may  be  no  pressure  symptoms, 
.-ind  irilics;ic  is  (illcd  with  ttiroiiihi,  no  ])ulsation. 


i 

Via.  250. — The  Interior  of  a  Fu-siform 
Aneurysmaij  Sac,  Showing  Openings 
AND  Groove  of  Main  Vessel  and  Open- 
ing   OF    COI.I-ATERAL     BuANCH.        (MataS, 

Hryatil's  "Operative  Kvirgory.") 


DISEASES  OF   THE   BLOOD   AND   LYMPHATIC   VESSELS 


673 


Tumors,  infiltrated  masses,  and  abscesses  lying  over  large  vessels 
(e.  g.,  carcinoma  of  the  stomach,  horseshoe  kidney,  inflannnatory  masses, 
tuberculous  abscesses,  and  nodes)  are  to  be  differentiated  from  aneu- 
rysms by  observing  carefully  the 
character  of  the  pulsation.  These 
are  merely  raised  or  displaced  by 
the  pulsation  transmitted  to  them, 
which  is  never  expansile  in  char- 
acter and  besides  no  bruit  can  be 
heard. 

Cavernous  and  racemose  angio- 
mas are  pulsating  tumors,  and  have 
to  be  differentiated  at  times 
from  arteriovenous  aneu- 
rysms.    The  vessels  of  a  cav- 
ernous angioma  are  never  so 
full  as  are  those  of  an  arterio- 
venous   aneurysm,     and    the    skin 
covering    such    an    angioma   has    a 
bluish  discoloration.     The  racemose 
angioma  is   composed   of  tortuous, 
dilated   arteries.     Sometimes   it   is 
very    difficult    to    differentiate    be- 
tween an  aneurysm  and  a  pulsating 
sarcoma. 

Treatment. — The  following  are 
the  principal  indications  which  are 
followed  to-day  in  the  surgical 
treatment  of  simple  and  ai'terio- 
venous  aneurysms:  (1)  Wherever 
possible  complete  or  incomplete  removal  of  the  sac  with  double  ligation 
of  the  artery  (vein  also  in  arteriovenous  aneurysms)  above  and  below  the 
aneurysm,  and  ligation  of  all  the  connuunicating  lateral  branches-,  (2) 
restoration  of  normal  conditions,  obliterating  the  aneurysm,  without  oc- 
cluding the  original  lumen  of  the  vessel,  by  suture  (^latas's  operation). 

Complete  extirpation  of  the  aneurysm  Avas  first  employed  in  the  treat- 
ment of  arterial  aneurysm  by  Philagrius.  After  an  ai'tificinl  ischoemia 
has  been  produced  by  the  Esmarch  method,  the  upper  and  lower  limits 
of  the  sac  are  exposed,  the  vessels  are  doubly  liiiated  and  divided,  and 
the  sac  removed.  Frequently,  in  operating  upon  large  false  aneurysms, 
parts  of  the  sac  Avhich  are  closely  adherent  to  veins  and  nerves  nnist  be 
left  behind.  When  in  such  cases  it  is  seen  that  the  sac  cannot  be  enucle- 
ated, it  should  be  split  open  and  as  much  removed  as  is  compatible  Avith 


Fig.  251. —  1  iii  ]  i  sii  oini  Aveurysm.  The 
first  row  of  --utun'-,  closing  the  orifices  by 
fine  chromicized  catgut  or  silk.  (Matas, 
Bryant's  "Operative  Surge^J^") 


674       SURGICAL  DISEASES,  EXCLUDING  INFECTIONS  AND  TUMORS 


safety.     This  method   has   given  the   best  results   in  the  trcmtnient   of 
arteriovenous  aneurysms  (von  Bramann,  von  Bergmann).     The  dangers 
.^^:  a;  of     gangrene     following     circulatoiy 

disturbances  induced  by  this  opera- 
tion (according  to  Delbet,  gangrene 
occurs  in  5.66  per  cent  of  the  cases) 
are  to  be  avoided  by  applying  im- 
mobilizing dressings,  loose  tampons 
where  they  seem  necessary, 
and'  by  elevating  the  extrem- 
ity. Digital  compression  ap- 
plied intermittently  for  some 
time  before  the  operation  fa- 
vors the  development  of  a  col- 
lateral circulation.  An  at- 
tempt should  be  made  to 
restore  the  lumen  by  sutiiring 


Fig.  252. — The  Fusiform  Aneurysm.  The 
second  row  of  sutures.  These  may  be 
the  interrupted  or  continuous.  If  floor  be 
rigid  the  second  row  may  be  omitted. 
(Matas,  Bryant's  "Operative  Surgery.") 


the    cut    ends    of    the 
vessels,    if    after    re- 
moval of  a  small  sac  they  arc  not 
too  far  removed  from  each  other. 
In    a    small    saccular    aneurysm, 
aneurysmal    varix,    and    arterio- 
venous  fistula   it   is   possible 
to  restore  the  lumen  of  the 
vessel.     After    removing   the 
sac  or  separating  the  vessels 
at   the   point   of   communica- 
tion,    the    defects    in    the    Avails 
should    be    closed    by    lateral    su- 
ture,  using   the   remnants   of   the 
sac  in  making  the  closure  (Matas). 


Fig.  253. — The  Fusiform  Anettrysm.  The 
second  row  of  sutvires  (continuous)  intro- 
(hicod;  tlie  final  obhtorating  sutures  passed 
at  cither  side.  On  the  loft,  transfixion  of 
floor  is  made.'  On  the  riglit  ends  of  simi- 
lar sutures  passed  through  integuments. 
(Matas,  Bryant's  "Operative  Surgery.") 


DISEASES   OF  THE   BLOOD   AND   LYMPHATIC   VESSELS 


675 


Incision  of  the  sac  and  luniiiKj  (ml  of  llu  hlood  clols  al'lcr  liga- 
tion of  the  artery  al)ove  and  below  tlie  aneurysm  is  a  iiietliod  whieh 
dates  back  to  Antylhis.  It  is  used  instead  of  extirpation  in  the  cases 
in  which  the  latter  seems  to  be  impossible  because  of  the  size  of  the 
aneurysm.  After  the  interior  of  the  sac  is  exposed,  the  lateral 
l)ranches  are  looked  for  and  ligated  and  then  the  cavity  of  the  sac  is 
tamponed. 

Proximal  ligation  of  the  afferent  arterial  trunlc  close  to  the  aneurysm 
(Anel),  or  at  some  distance  from  it  (Hunter),  may  cause  coa<;'ulation 
within  and  contraction  of  the  sac  and  result  in  a  cure.     Blood  may  be 


Fig.  254. — The  Fusiform  Aneurysm. 

The  deep  supporting  sutures  in  place,  and  passing 

their  ends  through  skin  and  aneurysmal  wall. 


poured  into  the  sac  again  when  the  collateral  circulation  is  established 
after  these  operations,  and  then  the  aneurysm  recurs.  There  is  also  a 
possibility  that  pieces  of  thrombi  which  follow  proximal  ligation  may 
become  loosened  and  may  lodge  in  the  efferent  arterial  trunk,  causing 
embolic  gangrene.  Proximal  ligation  should  not  be  employed  in  the 
treatment  of  an  arteriovenous  aneurysm,  as  it  is  followed  (luite  freciuently 
by  gangrene,  the  arterial  blood,  when  the  collateral  circulation  is  estab- 
lished, passing  into  the  vein  below  the  ligature,  and  enoiigh  blood  does 
not  reach  the  peripheral  parts  to  maintain  the  life  of  the  tissues.  Ac- 
cording to  von  Bramann,  gangrene  developed  in  six  out  of  thirty-one 
cases  of  arteriovenous  aneurysms  in  which  proximal  ligation  of  the 
artery  was  performed. 


676      SURGICAL  DISEASES,  EXCLUDING  INFECTIONS  AND  TUMORS 


Central  and  pcviphcyal  ligation,  of  the  artery  in  simple  aneurysm 
(Vigier),  of  the  artery  and  vein  in  arteriovenous  aneurysms  with  divi- 
sion of  the  vessels  gives  better  results  than  proximal  ligation  alone. 


Fig.  255. — The  Sacciform  Aneurysm,  its 
Main  Orifice  and  the  Dotted  Outline 
OF  THE  Main  Vessel.  (Matas,  Bryant's 
"Operative  Surgery.") 


Fig.  256. — The  Sacciform  Aneurysm.  The 
closure  of  main  orifice  by  continuous  su- 
tures without  si3ccial  removing  of  himen. 
(Matas,  Bryant's  "Operative  Surgery.") 


Even    after    this    operation   the    aneurj'sm    may    recur,    as    the    lateral 
branches  have  not  been  ligated. 

Brasdof  and  Wi'adiop  have  recounnended  peripheral  ligation  of  the 
artery  in  the  ti'catmeiii  of  aneurysms  so  situated  that  it  is  impossible 
or  iiii[)facticahle  to  deal  witb  the  aneurysm  on  the  cardiac  side  of  tlie 
sac.  Tlic  blood  heeomes  stagnant  in  the  sac  after  distal  ligation,  thrombi 
fonri  vvliieli  later  become  organized,  resulting  in  obliteration  of  the  sac 
and  healing.  In  an  aneurysm  of  the  ascending  aor-ta  and  innominate 
arteiy,  the  right  subclavian  jind  common  carotid  arteries  should  be 
ligated.  Accoi-ding  to  11.  Jacobs's  statistics,  thirty-six  out  of  sixty-nine 
cases  treated  in  this  way  were  cured. 


DISEASES   OF   THE   BLOOD   AND   LYMPHATIC   VESSELS 


677 


If  symptoms  (especially  bruits)  of  a  pulsating  ha'matoma  or  of  an 
arteriovenous  fistula  develop  after  an  injury,  the  vessel  or  vessels 
involved  should  be  exposed  and  closed  by  lateral  arterial  or  venous 
suture  or  ligated  depending  upon  the  conditions  found.  The  develop- 
ment of  a  traumatic  or  arteriovenous  aneurysm  may  be  prevented  in 
this  way. 

Amputation  must  be  considered  in  the  treatment  of  large  aneurysms 
of  the  extremities  associated  with  nutritional  disturbances  and  necrosis, 
or  if  embolic  gangrene  develops. 

There  are  a  number  of  bloodless  methods  which  may  be  employed  in 
the  treatment  of  inaccessible  aneurysms,  such  as  those  of  the   aorta, 


Fig.  257. — The  Sacciform  Aneurysm.     Closure  of  the  main  orifice  by  interrupted  sutures 
without  special  removing  of  lumen.      (Matas,   Bryant's  "Operative  Surgerj'.") 


internal  carotid,  etc.,  or  when  operation  is  contraindicated  because  of  the 
age  or  weakened  condition  of  the  patient.  The  object  of  all  these  meth- 
ods is  to  produce  a  thrombosis,  for  when  the  thi-oml)i  become  organized 
the  aneurysm  becomes  smaller  and  its  walls  thicker.  Of  the  large  num- 
ber of  old  and  new  methods,  only  two  demand  consideration. 


678       SURGICAL  DISEASES,  EXCLUDING   INFECTIONS  AND  TUMORS 


Compression. — Continuous  or  intermittent  compression  of  the  affer- 
ent artery  may  be  employed,  some  special  apparatus  or  the  fingers  being 
used  for  the  purpose.  The  object  of  the  compression  is  merely  to  slow 
or  arrest  the  arterial  stream,  not  to  produce  a  passive  hypersemia.     Cir- 


FiG.  258. — The  Sacciform  Aneurysm.  Ob- 
literation of  orifice  coin])lcted,  lumen  in- 
tact. OiJoration  conipl(;ted  as  in  fusiform 
aneurysm.  (Matas,  Brj'ant's  "Operative 
Surgery.") 


Fig.  259. — The  Sacciform  Aneurysm  with 
Catheter  Introduced  to  Maintain 
Caliber  of  Lumen;  Sutures  Placed 
Over  Catheter.  (Matas,  Bryant's  "Op- 
erative Surgcr3\") 


eular  constriction  should  therefore  not  be  employed  for  this  purpose. 
Some  arterial  aneurysms  have  been  observed  in  which  the  symptoms  dis- 
appeared and  the  sac  decreased  in  size  after  compression  for  a  number 
of  hours.  In  other  cases  iiitei'iiiitteiit  compression  has  been  employed 
for  days  and  weeks  before  residts  were  obtained,  and  then  often  without 
success.  The  object  of  compression  is  so  to  reduce  the  blood  pressure 
as  to  permit  of  coagulation  within  the  sac  of  the  aneurysm.  According 
to  Vauzetti,  in  the  ti-eatment  of  arteriovenous  aneurysms  by  this  method 
tlif  artery  should  be  compressed  just  above  the  aneurysm  until  the 
pulse  (lisapjx'ars,  and  the  vein  at  the  point  of  comnumication  with  the 
sac  at  the  same  time.    Compression,  combined  with  rest  in  bed  and  im- 


DISEASES   OF   THE   BLOOD   AND   LYMPHATIC   VESSELS 


679 


mobilization  of  the  extremity,  should  l)e  ('mi)loyed  a  short  time  before 
operative  treatment  is  instituted.  Compression,  even  if  it  does  not  cure 
the  aneurysm,  favors  the  development  of  a  collateral  circulation  and 
may  prevent  subsequent  gangrene.  In  suitable  cases  forced  flexion  of 
the  extremity  may  be  employed  instead  of  instrumental  or  digital  com- 
pression. The  hyperflexed  parts  are  maintained  in  position  by  band- 
ages. This  method  can  be  employed  safely  only  in  the  treatment  of 
small  aneurysms,  as  the  larger  ones  are  apt  to  rupture,  and  in  the  treat- 
ment of  aneurysms  in  certain 
localities,  at  the  bend  of  the 
elbow,  in  popliteal  space,  and 
in  the  groin. 

It  should  be  remembered  that 
there  is  danger  of  rupturing 
large  aneurysms  when  using  digi- 
tal or  instrumental  compression. 

Gelatin  Treatment. — 
Dastre  and  Floresco  dem- 
onstrated experimentally 
that  subcutaneous  injec- 
tions of  a  solution  of  gela- 
tin increased  the  coagula- 
bility of  the  blood.  Lan- 
cereaux  and  Paulesco 
(1898)  recommended  gela- 
tin injections  for  the  treat- 
ment of  saccular  aneurysms. 
One  hundred  c.c.  of  a  one  or 
two  per  cent  solution  of  gela- 
tin (1-2  gm.  of  white  gelatin 
is  dissolved  in  100  c.c.  of  physi- 
ological salt  solution,  and  is 
sterilized  for  Ave  successive 
days  for  one  half  hour  over 
live  steam  at  212°  F.  and  heated 
to  99°  F.  before  being  used) 
should  be  injected  about  every  week.  Beck,  among  others,  cured  a  large 
aneurysm  of  the  aorta  in  two  months  by  this  treatment.  This  method, 
which  promised  much,  has  been  disappointing.  If  the  heart  is  weak  the 
increased  coagulability  of  the  blood  may  lead  to  the  formation  of  thrombi 
in  the  large  veins  (iliac  femoral),  and  if  the  sterilization  is  not  thor- 
ough and  reliable,  tetanus  may  follow  the  injection  {vide  Bass). 

Injections  of  chemical  agents  into  the  sac,  and  the  application  of 


Fig.  260. — The  Sacciform  Aneurysm.  The  re- 
moval of  catheter  before  final  closure  of  the 
main  channel.  (Matas,  lirj-ant's  "Operative 
Svirgcry.") 


680       SURGICAL   DISEASES,    EXCLUDING  INFECTIONS  AND  TUMORS 

elastic  bandages  about  the  extremity,  are  frequently  followed  by  gan- 
grene and  should  not  be  employed.  Acupuncture,  according  to  Velpeau 
(insertion  of  hot  needles  into  the  sac),  and  galvano-puncture  (intro- 
ducing gold  or  steel  wire  through  a  needle  or  canula  into  the  sac  and 
passing  the  galvanic  current  through  them)  are  not  very  often  indi- 
cated, as  the  treatment  is  often  not  successful  and  is  associated  with  the 
dangers  of  hiEmorrhage,  inflammation,  and  separation  of  thrombi. 

If  the  aneurysm  is  inoperable,  the  patient  should  be  kept  in  bed  or 
the  extremity  should  be  immobilized.  Sudden  increase  in  blood  pres- 
sure, such  as  follows  physical .  effort,  excitement,  and  the  use  of  al- 
coholic drinks,  should  be  avoided.  Treatment  by  starvation  and 
blood-letting,  as  prescribed  in  Valsalva's  method,  should  be  employed. 
Digitalis  and  tincture  of  strophanthus  may  be  used  to  quiet  the  heart, 
lodid  of  pota&sium  and  sodium  have  a  favorable  influence  upon  the  local 
and  general  conditions. 

Literature. — Bass.  Erfolge  unci  Gefahren  der  Gelatineapplikation.  Zentralbl. 
f.  d.  Grenzgebiete,  1904,  p.  118. — v.  Berginann.  Zur  Kasuistik  des  arteriell-vemisen 
traumatischen  Aneurysma.  Arch.  f.  klin.  Chir.,  Bd.  69,  1903,  p.  515. — -v.  Bramunn. 
Das  arteriell- venose  Aneurysma.  Arch.  f.  klin.  Chir.,  Bd.  73,  1886,  p.  1.^ — Delbet. 
Maladies  chir.  des  arteres.  Traite  de  chir.  le  Dentu  et  Delbet.  Paris,  1897. — Eppinger. 
Pathogenesis,  Histogenesis  und  Aetiologie  der  Aneurysmen.  Arch.  f.  klin.  Chir.,  Bd. 
35,  1887,  Suppl.,  p.  1. — Fr.  Fischer.  Krankheiten  der  Lymphgefasse,  Lymphdriisen  und 
Blutgefasse.  Deutsche  Chir.,  1901. — Franz.  Klinische  und  experimentelle  Beitrage 
betreffend  das  Aneurysma  arteriovenosum.  Arch.  f.  klin.  Chir.,  Bd.  75,  1905,  p.  572. — 
V.  Frisch.  Beitrag  z.  Behandl.  periph.  Aneurysmen.  Arch.  f.  klin.  Chir.,  Bd.  79,  1906, 
p.  515. — Jacobsthal.  Beitr.  zur  Statistik  der  operativ  behandelten  Aneurysmen.  I. 
Das  Aneurysma  der  Art.  anonyma.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  63,  1902,  p.  550. 
II.  Das  Aneurysma  der  Art.  subclavia.  Ibid.,  Bd.  68,  1903,  p.  239.  — Malkojf. 
Ueber  die  Bedeutung  der  traumatischen  Verletzung  von  Arterien  (Quetschung,  Dehnung) 
f  iir  die  Entwicklung  der  wahren  Aneurysmen  und  der  Arteriosklerose.  Zieglers  Beitrage 
zur  path.  Anat.,  Bd.  25,  1901,  p.  431. — Matas.  An  Operation  for  the  Radical  Cure  of 
Aneurism.  Transact,  of  the  Americ.  Surgical  Assn.,  vol.  20, 1902. — Orth.  Lehrbuch  der 
speziellen  pathol.  Anatomic,  I. — v.  Schrotter.  Die  Erkrankungen  der  Gefiisse.  Noth- 
nagels  Handbuch  d.  spez.  Path.  u.  Ther.,  Bd.  15,  Part  III,  Wien,  1901.— Sorgo.  Behand- 
lung  der  Aneurysmen  mit  subkutanen  Gelatineinjektionen.  Zentralbl.  f.  Grenzgeb,, 
1899,  p.  10. —  Thoma.  Untersuchungen  iiber  Aneurysmen.  Virchows  Archiv.,  111-113, 
1888; — Elastizitat  gesunder  und  kranker  Arterien.     Ibid.,  Bd.  116,  1889,  p.  1. 


(c)  PHLEBECTASES,  VARICES 

By  phlebectases  or  varices  is  understood  a  permanent  dilatation  of  the 
walls  of  large  and  small  veins.  The  former  term  is  used  more  frequently 
to  designate  the  fusiform,  cylindrical,  tortuous  (cirsoid)  dilatations, 
while  the  latter  is  applied  to  the  circumscribed  bulgings  of  the  vein 
wall  (varices),  which  still  maintain  their  connection  with  the  vein  by 
a  broad  or  narrow  neck.     There  are  a  number  of  transitional  forms,  so 


DISEASES   OF   THE   BLOOD   AND   LYMPHATIC   VESSELS 


681 


that  both  terms  are  usually  employed  with  about  the  same  genei'al  sig- 
liifleanee. 

Causes  of  Varicose  Veins. — There  are  a  number  of  etiological  factors 
which  contribute  to  the  development  of  varicose  veins.  Besides  the 
mechanical  factors  which  interfere  with  the 
venous  circulation  and  therefore  increase 
the  pressure  within  the  veins,  the  lessened 
resistance  of  the  walls  of  the  veins  and 
insufficiencj'  of  the  valves,  w^hicli  may  be 
congenital  or  secondary  to  inflammatory 
changes,  must  be  considered.  Usually  a 
number  of  different  etiological  factors  are 
combined,  one  following  and  accentuating 
another;  for  example,  if  the  valves  of  the 
veins  of  the  lower  extremities  have  under- 
gone contraction  and  become  insufficient, 
the  weight  of  the  entire  column  of  blood 
from  the  inferior  vena  cava  down  is 
thrown  upon  the  wall  of  the  vein.  If  the 
reverse  happens  and  the  walls  of  the  vein 
become  distended  by  the  weight  of  the 
colunni  of  blood,  the  valves  become  insuf- 
ficient and  are  no  longer  able  to  break  the 
column  of  blood  and  assist  in  venous  cir- 
culation. If  the  stasis  is  long-continued, 
the  walls  of  the  veins  become  inelastic  and 
yielding,  the  circulation  in  the  vasa  vaso- 
rum  is  interfered  with  and  the  nutrition 
of  the  tissues  of  the  vein  wall  gradually  is 
impaired,  leading  to  a  dilatation  of  the 
vein  with  relative  insufficiency  of  the 
valves  and  venous  stasis.  According  to 
Ledderhose,  too  nnich  importance  has  been 
attri])uted  to  the  valves  in  assisting  in  and 

maintaining  venous  circulation.     Most  authorities,  however,  at  the  pres- 
ent time  attribute  to  the  vah^es  a  very  important  function. 

Pathological  Changes  in  Varicose  Veins. — Some  parts  of  a  varicose 
vein  may  be  practically  normal,  while  in  other  parts  the  muscular  and 
elastic  elements  disappear,  being  replaced  by  a  fibro-cicatricial  tissue, 
while  in  still  other  parts  (especially  ^vhere  the  pouchlike  dilatations 
occur)  the  vein  wall  is  thin  and  atrophic.  The  veins  are  more  or  less 
adherent  to  surrounding  structures,  the  adhesions  being  partly  due  to 
nutritional  disturbances,  partly  to  inflammatory  changes  in  the  peri- 
44 


4 

Fig.  261. — Resected  Piece  op 
THE  Long  Saphenous  Vein 
(Filled  with  Paraffine). 
1,  cylindrical;  2,  fusiform;  3, 
tortuous  plilebectases;  4,  varix. 


682       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 


vascular  tissues.  The  slowing  of  the  blood  stream  and  the  })roliferation 
of  the  intima  predispose  to  the  development  of  thrombi.  If  the  thrombi 
become  calcified,  vein  stones  or  phleholiths  are  formed.  A  varix,  which 
may  become  as  large  as  a  hen's  egg,  may  become  constricted  and  sepa- 
rated from  the  vein  wall  at  the  point  at  which  it  formerly  connnuni- 
cated.  In  this  way  a  blood  cyst  may  develop.  Large,  tortuous,  and 
convoluted  veins  may  be  in  direct  communication  with  one  another,  as  the 

walls  of  the  vein  when  in  contact  may  under- 
go a  pressure  necrosis  and  a  communication 
may  be  established    (anastomosing  varices). 

Veins  Most  Commonly  Involved — Age,  Sex, 
Occupation. — Haemorrhoids  (dilated  hemor- 
rhoidal veins  or  plexuses)  are  the  most  com- 
mon type  of  varicose  veins.  Normally,  even 
in  childi'en,  small  dilatations  may  be  demon- 
strated in  the  veins  about  the  anus  (annulus 
hannorrhoidalis),  which  become  transformed 
into  varices  as  the  result  of  chronic  consti- 
pation and  inflammation  of  the  mucous  mem- 
brane. Some  authors  (Reinbach,  Gunckel, 
Rotter,  Ziegler)  regard  haemorrhoids  as  cav- 
ernous angiomas  and  classify  them  as  new 
growths,  while  others  (Borst,  Kaufmann, 
Ribbert)  regard  them  merely  as  varicose 
veins.  [Haemorrhoids  are  histologically  an- 
giomas in  which  the  venous  elements  pre- 
dominate.] 

Next  in  order  of  frequency  are  varicose 
veins  of  the  lower  extrenuty,  both  the  super- 
ficial and  deep  veins  being  involved.  Vari- 
cose veins  are  most  common  in  individuals 
of  middle  age,  whose  occupation  re- 
(piires  them  to  stand  a  great  deal,  in 
women  who  have  borne  children,  in  pa- 
tients with  pelvic  tumors,  and  in  young 
people  with  a  congenital  weakness  of 
the  vein  walls.  Blue  nodules,  saccu- 
lated and  tortuous  dilatations,  and  con- 
volutions are  seen  in  tlie  course  of  the  long  and  short  saphenous 
veins,  over  which  the  skin  is  more  or  less  thinned.  These  empty  when 
pressure  is  made  upon  them  or  the  extremity  is  elevated,  leaving  deep 
grooves  in  tlic  thinned  skin.  When  Ihe  upright  position  is  assumed 
again  and  llic  j»ivssui-e  is  released,  the  blood  flows  back  into  the  veins 


Fig 


202. — Varicose   Veins  of  the 
lowek  i'^xtremity. 


DISEASES   OF   THE   BLOOD   AND   LYMPHATIC    VESSELS  683 

from  above,  and  the  veins  do  not  fill  from  below  as  the  valves  are  insuf- 
ficient. [This  test  was  first  used  by  Trendelenburg  and  may  be  employed 
in  the  following  way :  The  patient  lies  down  and  the  veins  are  allowed 
to  empty.  Pressure  is  then  made  upon  the  saphenous  vein  at  the  saphe- 
nous opening,  and  maintained  while  the  patient  is  assuming  the  upright 
position.  When  the  pressure  is  released  the  column  of  blood  drops  back 
from  above,  showing  that  the  valves  are  insufficient.] 

The  small  veins  of  the  skin  are  red  and  injected.  Varicose  veins  in 
the  upper  extremity  are  rare,  and  are  usually  due  to  pressure  of  tumors 
upon  the  axillary  or  subclavian  vein,  or  are  associated  with  ai'terio- 
venous  or  cirsoid  aneurysms. 

A  varicose  condition  of  the  pampiniform  plexus  is  known  as  a  vari- 
cocele. Varicoceles  are  common  in  young  adults.  Varicose  veins  also 
develop  in  later  adult  life  within  the  broad  ligament,  the  prostate,  about 
the  neck  of  the  bladder  and  the  external  genitalia,  in  the  utero-vaginal, 
vesical,  and  pudendal  plexuses.  The  veins  of  the  abdominal  wall  sur- 
rounding the  umbilicus  dilate  to  form  the  caput  Medusfe  when  the 
portal  circulation  is  obstructed  by  thrombosis  or  in  cirrhosis  of  the 
liver,  aiding  in  the  establishment  of  a  collateral  circulation.  The  sub- 
cutaneous veins  of  the  thorax  become  dilated  in  tumors  of  the  medi- 
astinum. 

Results  of  Varicose  Veins. — The  results  of  varicose  veins  are  circu- 
latunj  and  nutritional  disiurhcuices.  These  are  most  pronounced  when 
the  veins  of  the  loAver  extremities  are  involved.  The  skin  becomes 
thinned  and  atrophic,  susceptible  to  all  kinds  of  infection,  injuries,  and 
necrosis  {vide  p.  506).  Varicose  ulcers,  eczema,  and  thrombophlebitis 
are  frequent.  An  oedema,  varying  in  degree,  follows  the  passive  hyper- 
a?mia  and  leads  to  a  gradual  thickening  and  induration  of  the  skin  and 
subcutaneous  connective  tissues  (elephantiasis  phlebectatica).  Weak- 
ness of  the  legs  and  fatigue  are  common,  and  are  due  in  part  to  the 
circulatory  disturbances,  in  part  to  the  fibrous  myositis  with  secondary 
degeneration  of  the  muscle  fibers.  Cramplike  muscular  contractions 
and  neuralgic  pains  are  of  frequent  occurrence  when  the  deeper  veins 
are  involved.  Submucous  varices  may  cause  an  atrophy  of  the  nuicous 
membrane,  a  varicocele,  atrophy  of  the  testicle. 

Dangers  of  Varicose  Veins. — The  dangers  of  varicose  veins  are  liceni- 
orrhage  and  thrombophlebitis.  Hemorrhage  follows  rupture  of  a  pouch- 
like  dilatation  of  the  vein  wall  and  the  atrophic  skin  or  mucous  mem- 
brane covering  it.  It  is  usually  due  to  a  sudden  increase  in  venous 
pressure  resulting  from  tlu'  imperfect  application  of  an  Ksmarch  con- 
strictor or  the  dependent  ])ositi()n  of  tlie  extremity.  Such  a  luemorrhage 
may  prove  fatal,  as  a  colunni  of  blood  extending  to  the  right  auricle 
is  opened  near  its  lower  end. 


684       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND  TUMORS 

Hasmorrhoids  rupture  and  bleed  very  frequently  (therefore  the 
name).  Occasionally  varicose  veins  rupture  into  the  hollow  viscera 
(rupture  of  oesophageal  varices  in  cirrhosis  of  the  liver  and  of  varices  of 
the  brain)  terminating  fatally.  A  sudden,  frequently  painful,  swelling 
develops  when  varicose  veins  in  a  muscle  rupture. 

Diagnosis. — The  diagnosis  of  superficial  varicose  veins  is  difficult 
only  when  the  dilatations  are  limited  to  a  small  part  of  the  vein  and 
are  circumscribed.  In  these  cases  a  diagnosis  of  a  cavernous  ha^man- 
gioma  may  be  made.  Deep  varicose  veins  give  rise  to  no  definite  symp- 
toms. The  dilated,  pulsating  veins  occurring  in  arteriovenous  aneurysm 
offer  no  difficulty  in  diagnosis  if  a  careful  examination  is  made.  The 
varices  occurring  over  the  saphenous  opening  and  varicocele  are  some- 
times mistaken  for  femoral  and  inguinal  hernia  respectively,  but  differ 
from  hernia  in  that  the  swelling  disappears  so  readily  when  pressure 
is  made  or  when  the  patient  lies  down,  and  recurs  so  readily  when  the 
patient  stands  up. 

Treatment. — The  treatment  which  should  be  instituted  depends  upon 
the  cause,  the  situation,  and  the  complications  of  the  varicose  veins. 

Varicose  veins  frequently  subside  after  tumors  (which  have  exerted 
pressure  upon  the  principal  vein  and  have  caused  an  increased  venous 
pressure)  have  been  removed.  Ligation  of  the  long  saphenous  vein  at 
the  saphenous  opening,  as  suggested  by  Trendelenburg,  breaks  the  long 
column  of  venous  blood  and  prevents  pressure  upon  the  wall  of  the  vein. 

Elastic  bandages  properlj^  applied  and  elevation  of  the  extremities 
have  a  favorable  influence  upon  varicose  veins  of  the  extremities.  A 
suspensory  improves  the  circulation  in  a  varicocele,  and  the  pain  and 
discomfort  usually  soon  disappear  after  it  is  used. 

Large  varicose  veins  and  varicoceles  should  be  extirpated  after  the 
veins  have  been  exposed  and  ligated.  In  varicose  veins  of  the  leg  exten- 
sive and  thorough  resection  of  the  diseased  veins  (Madelung)  or  ligation 
and  resection  of  the  long  saphenous  vein  at  the  saphenous  opening  are 
recommended  (Trendelenburg).  [C.  H.  Mayo  has  devised  a  very  in- 
genious instrument,  called  a  "  vein  stripper,"  which  permits  of  a  sub- 
cutaneous removal  of  the  greater  part  of  the  varicose  vein.  It  is  a 
long  instrument,  provided  with  a  steel  eye.  The  vein  is  exposed  above 
through  a  small  transverse  incision,  cut  and  ligated,  and  then  threaded 
upon  the  instrument.  The  vein  is  then  separated  from  the  tissues,  and 
its  collaterals  are  broken  by  gently  forcing  the  "  stripper  "  along  the 
vein.  Another  small  incision  is  then  made  over  the  end  of  the  instru- 
ment, tlic  distal  portion  of  the  vein  is  ligated,  and  the  part  which  has 
been  sci)ai'ated  is  removed.]  Ihemoi-rhoids  should  be  removed  with  the 
actual  cautery  or  transfixed  at  the  base  with  heavy' silk  and  ligated. 

Bleeding  from  varicose  veins  subsides  if  the  extremity  is  elevated 


DISEASES   OF   THE   BLOOD   AND   LYMPHATIC   VESSELS  685 

or  mild  compression  is  exerted  by  a  bandage.  Ilannorrhage  from  ha-iuor- 
rlioids  generally  ceases  when  the  prolapsed,  strangulated  masses  are 
reduced.  Extirpation  of  the  larger  ruptured  varices  is  advised.  The 
treatment  of  other  complications,  such  as  thrombophlebitis  and  varicose 
ulcers,  will  be  found  in  the  chapters  devoted  to  these  subjects. 

Literature. — Fr.  Fischer.  Krankheiten  der  Lymphgefiisse,  Lymphdriisen  urid 
Blutgefjisse.  Deutsche  Chir.,  190 L — F.  Fruenkel.  Ueber  die  Behandluiig  der  Varizen 
der  LTnteren  Extremitiit  durch  Ausschidung  nach  Madelung.  Beitr.  z.  klin.  Chir.,  Bd. 
30,  1902,  p.  547. — Kashimura.  Die  Entstehung  der  Varizen  der  Vena  saphena  in  ihrer  Ab- 
hiingigkeit  vom  Gefassnervensystein.  Virchows  Arch.,  Bd.  179,  1905,  p.  373. — Ledder- 
hose.  Die  Bedeutung  der  Venenklappen  und  ihre  Beziehungen  zu  den  Varizen.  Deutsch. 
nied.  Wochenschr.,  1904,  p.  1563. — v.  Schrotter.  Erkrankungen  der  Gefiisse.  Noth- 
nagels  Spez.  Path.  u.  Ther.,  Wien,  1901. — Schwarz.  Maladies  chir.  des  veines.  Traite 
de  chir.  le  Dentu  et  Delbet.     T.  IV,  p.  349.     Paris,  1897. 

(d)  THROMBOSIS  AND  EMBOLISM 
THROMBOSIS 

The  coagulation  of  blood  within  the  vessels  during  life  is  known  as 
thrombosis,  and  the  resulting  solid  mass  as  a  thrombus  (from  the  Greek 
0p6iJ,/3o<;,   meaning  coagulum). 

Varieties  of  Thrombi  and  Histological  Changes  Occurring  in  Throm- 
bosis.— Red,  white,  and  mixed  thrombi  have  been  distinguished  since 
Zahn  first  described  the  microscopic  changes  occurring  in  thrombosis 
of  the  mesenteric  vessels  of  a  frog.  The  color  of  a  thrombus  depends 
upon  the  number  of  red  blood  corpuscles  it  contains.  The  red  throm- 
bus contains,  besides  granules  and  threads  of  fibrin,  all  the  component 
parts  of  the  blood,  and  is  formed  when  stagnant  or  slowly  flowing  blood 
coagulates.  Thrombi  formed  from  blood  in  circulation,  which  not  in- 
frequently occur  upon  the  internal  surface  of  the  heart  and  blood  ves- 
sels, are  composed  mostly  of  fibrin,  with  a  variable  number  of  the  color- 
less elements  of  the  blood,  and  contain  sometimes  a  few  red  cells.  White 
and  mixed  thrombi  are  formed  when  the  circulating  blood  coagulates. 
[The  following  description  of  the  formation  of  thrombi  is  found  in 
Ziegler's  "  General  Pathology,"  pp.  117  and  118:  "  The  formation  of 
thrombi  in  circulating  blood  may  be  observed  distinctly  un3er  the  micro- 
scope, in  suitable  subjects,  both  in  warm-blooded  and  cold-blooded  ani- 
mals, and  in  this  line  it  is  more  particularly  the  observations  of  Bizzo- 
zero,  Eberth,  Schimmelbusch,  and  Lowit  which  have  led  to  very  weighty 
conclusions.  When  the  blood  flows  through  a  vessel  with  its  normal 
velocity,  you  may  see  under  the  microscope  (Bizzozero,  Eberth,  and 
Schimmelbusch)  a  broad,  homogeneous,  red  stream  in  the  axis  of  the 
blood  vessel,  while  at  the  sides  lies  a  clear  zone  of  blood-plasnui  free 
from  red  blood  corpuscles. 


686      SURGICAL   DISEASES,   EXCLUDING  INFECTIONS  AND  TUMORS 

"  This  may  be  observed  in  both  arteries  and  veins  and  in  the  larger 
capillaries,  but  is  best  seen  in  the  veins.  In  the  capillaries  just  large 
enough  to  permit  of  the  passage  of  the  blood  corpuscles,  this  differen- 
tiation into  an  axial  and  peripheral  stream  does  not  hold.  In  the  axial 
stream  the  different  constituents  of  the  blood  are  not  recognizable;  in 
the  peripheral  stream,  however,  isolated  white  blood  corpuscles  appear 
from  time  to  time,  and  these  may  be  seen  to  roll  slowly  along  the  vessel 
wall.  If  the  blood  current  becomes  retarded  to  about  the  degree  which 
allows  the  observer  to  make  out  indistinctly  the  blood  corpuscles  of  the 
axial  stream,  the  number  of  white  blood  corpuscles  floating  slowly  along 
in  the  peripheral  zone,  and  adhering  also  at  times  to  the  vessel  wall, 
becomes  increased,  and  they  finally  come  to  occupy  this  zone  in  consid- 
erable numbers.  If  the  current  be  still  further  retarded  so  that  the 
red  blood  corpuscles  become  clearly  recognizable,  then  in  the  peripheral 
zone  alongside  of  the  white  blood  corpuscles  appear  blood  platelets, 
which  increase  more  and  more  in  number  with  the  progressive  retarda- 
tion of  the  flow,  Avhile  the  number  of  leucocytes  becomes  again  dimin- 
ished. When  total  arrest  of  the  blood  current  finally  occurs,  a  distinct 
separation  of  the  corpuscular  elements  in  the  lumen  of  the  vessel  follows. 

"  When,  in  a  vessel  in  which  circulation  is  retarded,  the  intima  is 
injured  at  a  certain  point  by  compression  or  by  violence,  or  by  chem- 
ical agents,  such  as  corrosive  sublimate,  nitrate  of  silver,  or  strong  salt 
solutions,  and  the  lesion  of  the  vessel  wall  is  of  such  a  character  that 
it  does  not  cause  arrest  of  the  blood  current,  we  may  observe  (Bizzozero, 
Eberth,  Schimmelbusch)  blood  plates  adhering  to  the  vessel  wall  at  the 
injured  point,  and  before  long  they  cover  the  site  of  the  injury  in 
several  layers. 

"  Frequently  more  or  less  numerous  leucocytes  or  colorless  blood 
corpuscles  become  lodged  in  the  mass  (Bizzozero),  and  their  number  is 
proportionate  to  their  abundance  in  the  peripheral  zone.  Under  some 
circumstances  the  number  of  leucocytes  may  be  very  considerable,  and 
they  may  largely  cover  over  the  accumulation  of  blood  plates.  In  case 
of  great  ii-regularity  of  the  circulation  or  of  extensive  lesions  of  the 
vascular  wall,  red  l)lood  corpuscles  also  may  separate  from  the  circula- 
tion and  become  adherent  to  the  intima  or  to  a  layer  of  leucocytes  pre- 
viously deposited  upon  it.  Not  infrequently  portions  of  the  separated 
mass  are  swept  away,  in  which  case  a  new  deposit  of  blood  i)lates  is 
formed.  Through  a  long-continued  deposition  of  the  elements  of  the 
blood  the  vessel  may  finally  become  completely  closed. 

Should  a  blood  vessel  suffer  a  lesion,  as  above  described,  while  the 
current  of  hlood  within  it  still  remains  swift,  there  is  no  adherence  of 
blood  plates  or  of  blood  corpuscles.  When  at  any  point  blood  plates 
have  become  adherent  in  considerable  numbers,  after  a  time  they  be- 


DISEASES   OF   THE   BLOOD   AND   LYMPHATIC    VESSELS  6S7 

come  coarsely  granular  at  the  center,  granular  or  homogeneous  at  the 
periphery,  and  finally  become  fused  into  one  compact  mass.  The  final 
result  of  the  process  is  the  formation  of  a  colorless  blood-plate  thrombus, 
within  which  hiore  or  less  numerous  white  blood  corpuscles  may  be 
imprisoned.  Eberth  designates  the  sticking  together  of  the  blood  plates 
by  the  term  conglutination;  their  final  fusion  into  a  coherent  thrombus 
he  calls  viscous  metamorphosis. 

"  If  we  compare  the  observations  of  Bizzozero,  Eberth,  and  Schim- 
melbusch,  as  well  as  the  recent  observations  of  Lowit,  on  warm-blooded 
animals  with  the  histological  findings  in  thrombi  from  the  human  sub- 
ject, we  are  warranted  in  drawing  the  conclusion  that  the  formation  of 
thrombi  in  the  circulating  blood  of  man  procjeeds  in  a  way  similar  to 
that  observed  in  the  lower  animals,  and  we  judge  that  their  formation 
is  directly  dependent  upon  two  causes:  (1)  Upon  a  retardation  of  the 
blood  current  or  other  disturbance  of  the  circulation,  such  as  the  forma- 
tion of  eddies  A\hieh  would  direct  the  blood  plates  against  the  vascular 
wall,  and  (2)  upon  local  changes  in  the  wall  of  the  vessel.  Probably,  too, 
thrombosis  is  favored  by  pathological  changes  in  the  blood.  From  the 
variety  of  conditions  under  which  thrombosis  occurs  in  man  we  must 
assume  either  that  now  one  and  again  another  of  these  causes  plays  the 
principal  part  in  the  formation  of  thrombi,  or  that  all  these  may  concur 
equally  in  the  process;  and,  on  the  other  hand,  that  one  of  the  causes 
alone  is  not  ordinarily  sufficient  to  cause  thrombosis.  "J 

Orig^in  of  Blood  Plates,  Fibrin  Ferment,  etc. — The  finer  processes  of 
thrombus  formation  are  not  well  understood.  The  origin  and  signi- 
ficance of  the  blood  plates  discovered  by  Bizzozero  are  not  clear.  Accord- 
ing to  the  prevailing  view  they  are  formed  from  degenerating  red  blood 
corpuscles,  yet  it  is  possible  that  they  have  no  single  source  ((irawitz). 
Liberation  of  fibrin  ferment  or  thrombin  (Alex.  Schmidt)  precedes 
coagulation.  It  apparently  is  derived  from  degenerating  cells  (white 
and  red  blood  corpuscles  and  endothelial  cells)  and  acts  upon  fil)rinogen, 
an  albuminous  substance  in  the  blood  plasma.  According  to  Arthus 
and  Pages  a  third  factor,  a  calciinn  salt,  must  be  present  before  coagu- 
lation can  take  place.  Pekelharing  believes  that  calcium  is  transferred 
by  the  fibrin  ferment  to  the  fibrinogen,  and  that  the  latter,  which  was 
previously  soluble,  undergoes  a  chemical  metamorphosis  resulting  in  the 
formation  of  an  insoluble  calcium-albumin  compound,  fibrin. 

Factors  Concerned  in  Thrombus  Formation. — Three  different  factors 
are  concerned  in  thrombus  formation:  (1)  Slowing  of  the  blood  current, 
(2)  changes  in  the  vessel  wall,  and  (3)  alterations  in  the  composition 
of  the  blood. 

Slowing  of  the  blood  stream,  following  the  general  circulatory  dis- 
turbances due  to  cardiac  asthenia  which  occur  in  a  number  of  different 


688       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND   TUMORS 

diseases,  is  the  main  factor  in  the  development  of  the  so-called  marantic 
(marasmic)  thromhi.  Local  causes  interfering  with  circulation  are  nar- 
rowing of  the  lumen  of  the  vessel  caused  by  disease  of  the  vessel  wall 
(arteriosclerosis),  or  compression  of  the  vessel  by  tumors,  displaced 
fragments  of  bone,  dislocated  bones  and  constricting  bandages,  and  the 
development  of  whirls  and  eddies  in  aneurysms  and  in  pouchlike  dila- 
tations in  the  walls  of  varicose  veins. 

A  very  insignificant  injury  of  the  endothelium  lining  a  vessel  may 
be  followed  by  thrombus  formation,  and  of  course  a  thrombus  is  much 
more  apt  to  form  when  the  injury  to  the  vessel  wall  is  more  extensive^ 
Large  arteries  are  closed  spontaneously  when  crushed  or  lacerated  by 
the  separation  and  rolling  in  of  the  intima.  [The  rolling  up  of  the 
intima  prevents  haemorrhage  after  crushed  and  lacerated  w^ounds  of  even 
the  largest  arteries.  AVe  have  seen  an  axillary  artery  completely  plugged 
by  endothelium  in  a  crushing  injury  of  the  shoulder.  At  least  an  inch 
of  the  intima  could  be  unrolled  when  the  artery  was  divided  after  being 
ligated.  The  endothelium  had  formed  a  comjilete  plug  for  the  vessel.] 
Spontaneous  healing  of  small  wounds  of  vessels  begins  with  thrombus 
formation  (vide  Injuries  of  Vessels).  Changes  in  the  vessel  walls  due 
to  chemical  and  thermal  agents,  to  diseases,  such  as  arteriosclerosis, 
suppurative  and  tuberculous  inflammation  favor  thrombus  formation. 
Thrombus  formation  may  also  follow  penetrating  wounds  (e.  g.,  needles) 
and  infiltration  of  the  vessel  wall  by  tumor  masses. 

Alterations  in  the  composition  of  the  Itlood  may  increase  its  coagu- 
lability. The  increased  coagulability  of  the  blood  in  general  infections 
(general  pyogenic  infections,  typhoid  fever,  influenza,  etc.),  in  diseases 
of  the  blood  (chlorosis),  and  after  extensive  burns  is  probably  due  to 
the  increase  in  fibrin  ferment  resulting  from  an  increased  destruction 
of  cells. 

Mural  and  Obturating  Thrombi. — Parietal,  or  mural,  and  obturating 
throiii1)i  are  described,  depending  upon  their  relation  to  the  vessel  con- 
taining them.  Fibrin  may  be  deposited  upon  a  parietal  thrombus,  which 
then  enlarges  until  it  may  become  an  obturating  thrombus.  A  throm- 
bus either  remains  limited  to  the  point  at  which  it  develops,  in  which 
case  it  is  firmly  attached,  or  gradually  grows  as  new  masses  of  fibrin 
ai-e  deposited,  and  ext(>]ids  fi-om  a  small  into  a  larger  vessel  or  vice 
versa ;  for  example,  a  thrombus  developing  in  a  small  vein  of  the  foot 
may  extend  to  the  inferior  vena  cava.  Such  a  thrombus,  however,  is 
nevei-  firmly  attached  tlirougbout  to  the  intima.  T^pon  section  thi'ombi 
often  have  a  sti-eaked  a})peai"inee  and  iiT(>gular  markings,  brighter  and 
dnrker  areas  alleiiiating.  Not  infrcfiuently  it  happens  that  a  red  throm- 
bus is  supei-added  to  a  white  or  mixed  thrombus  as  the  coagulation 
began  in  circulating  blood,  and  after  the  vessel  is  occluded  the  blood 


DISEASES   OF   THE    BLOOD   AND    LYMPHATIC    VESSELS  689 

becomes  stagnant  and  the  whole  mass  then  eoaguhites.  Tliroml)i  Torm- 
ing  in  aneurysmal  sacs  are  fre(iuently  laminated,  for  thrombosis  is  not 
continuous  and  progressive,  but  occurs  at  intervals,  so  that  the  newly 
formed  layers  of  coagulum  do  not  become  firndy  attached  to  the  old. 

Changes  Occurring  in  Thrombi. — Thrombi  may  undei-go  a  number  of 
ditt'erent  changes,  such  as  conlraction,  calci/kation,  simple  and  septic 
softening,  and  organization.  A  thrombus  in  the  beginning  is  soft  and 
contains  fluid,  but  after  a  time  the  fibrin  contracts,  expressing  the  fluid, 
the  cells  enclosed  within  the  meshes  of  the  fibrin  degenerate,  and  the 
mass  becomes  dry  and  firm.  A  vessel  which  has  been  completely  closed 
may  become  patent  again  when  the  thrombus  contracts.  If  lime  salts 
are  deposited  in  the  thrombus  or  the  mass  which  replaces  it,  vein  or 
artery  stones  (phleboliths  and  arterioliths)  are  formed.  When  a  throm- 
bus undergoes  simple  softening  the  central  portion  becomes  transformed 
into  a  grayish  red,  caseous,  degenerating  mass  which,  after  the  external 
layers  degenerate,  is  broken  up  and  discharged  into  the  blood  stream, 
giving  rise  to  emboli.  Suppurative  or  putrefactive  softening  is  due  to 
inflannnation  of  the  vessel  Avail,  resulting  from  the  invasion  of  pyogenic 
or  putrefactive  bacteria.  It  may  be  followed  by  the  discharge  into  the 
blood  stream  of  numerous  infected  emboli.  The  most  favorable  change 
in  a  thrombus  is  organization.  A  vascular,  germinal  tissue  which  de- 
velops from  proliferating  endothelium  invades  and  replaces  the  throm- 
bus which  becomes  transformed  into  firm  connective  tissue,  and  the 
vessel  is  either  pcu-manently  closed  or  its  wall  is  thickened. 

Symptoms  of  Thrombosis. — The  symptoms  of  thrombosis  are  not  pro- 
nounced unless  one  of  the  larger  arteries  is  completely  occluded.  Nu- 
tritional disturbances  then  develop  which  may  end  in  gangrene  unh'ss 
a  sufficient  collateral  circulation  is  established.  Stasis  is  the  principal 
symptom  of  venous  thrombosis.  Other  symptoms  due  to  separation  of 
particles  of  the  thrombus  and  subseciuent  embolism  are  frequent. 

Thrombi  develop  in  arteries  after  injuries  of  the  vessel  wall,  in  aneu- 
rysms, in  acute  inflammation  or  chronic  diseases  of  the  vessels,  and  after 
the  lodgment  of  emboli  originating  from  thrombi  within  the  heart  or 
larger  vessels. 

Venous  thrombi  develop  very  frequently  in  phlebitis  and  in  chronic 
diseases  in  which  cardiac  weakness  and  the  absoi'ption  of  toxins  co- 
operate in  producing  conditions  favoring  thrombosis.  The  veins  of  the 
lower  extremity  are  involved  most  frequently,  for  the  circulation  is  not 
only  poor  in  these  veins  if  they  are  dilated,  but  phlebitis  is  also  common. 

When  venous  thrombosis  occurs  there  may  be  found  along  the  course 
of  the  subcutaneous  veins  hard,  painful,  tortuous  cords  and  considerable 
oedema.  In  thrombosis  of  the  femoral  vein  there  develops,  besides  the 
hard  cord  the  size  of  a  thinnb,  cyanosis  and  marked  oedema  which  fre- 


690       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 

qiiently  becomes  chronic,  resulting  in  permanent  enlargement  of  the 
limb.  Thrombi  may  develop  in  the  veins  of  the  pampiniform  plexus 
of  the  female  after  infections  and  operations,  and  extend  by  way  of  the 
internal  iliac  into  the  femoral  vein.  (Edema  of  one  or  both  legs  then 
develops,  and  the  resulting  clinical  picture  resembles  that  known  as 
phlegmasia  alba  dolens,  following  puerperal  infections.  Suppurative 
otitis  media  is  frequently  the  cause  of  thrombosis  of  the  sigmoid  sinus. 
The  thrombus  forming  in  tliis  sinus  may  extend  to  communicating 
sinuses  and  to  the  internal  jugular  vein.  Thrombosis  of  the  veins  of  the 
mesentery  may  follow  internal  strangulation  or  the  incarceration  of 
intestinal  loops  or  omentum  in  a  hernia.  The  thrombi  may  then  extend 
to  the  portal  vein,  causing  marked  stasis  in  the  territory  drained  by  the 
radicles  of  this  vein.  Large  veins,  such  as  the  superior  and  inferior 
vena  cava  and  subclavian,  may  be  closed  by  thrombi  extending  into 
them  from  smaller  radicles  or  by  thrombi  caused  by  the  pressure  of  large 
tumors  or  aneurysms.  If  a  sufficient  collateral  venous  circulation  is 
established  the  cedema  gradually  subsides.  Gangrene  develops  only 
when  all  the  veins  draining  an  area  or  organ  become  closed  by  thrombi. 

EMBOLISM 

The  dangers  of  embolism  are  associated  with  thrombosis.  Particles 
of  thrombi  may  be  broken  off  by  trauma,  separated  by  violent  move- 
ments, or  discharged  spontaneously  when  the  thrombus  undergoes  sim- 
ple or  puriform  softening.  The  advancing  end  of  a  thrombus  which 
has  extended  from  a  small  vein  or  artery  into  the  lumen  of  a  larger 
vein  or  artery  may  be  separated  and  carried  away  into  the  blood  stream. 

Lodgment  of  an  Embolus. — An  embolus  originating  in  the  left  heart 
or  one  of  the  lai-ger  arteries  may  be  carried  in  the  blood  stream  until  it 
either  lodges  at  the  point  of  bifurcation  of  an  artery,  where  it  may 
remain  attached  as  a  saddle-shaped  embolus  occluding  both  branches, 
or  may  be  carried  along  until  the  lumen  of  the  artery  is  so  reduced  that 
it  becomes  caught.  If  an  important  artery  is  occluded,  gangrene  of  the 
part  supplied  by  the  artery  accompanied  by  violent  symptoms  frequently 
follows,  as  a  collateral  circulation  sufficient  to  provide  for  the  nutrition 
of  the  tissues  is  not  established  rapidly  enough  {vide  p.  497).  Infected 
ciiiboli  may  cause  arteritis  and  embolomycotic  aneurysms. 

Pulmonary  Embolism. — Venous  emboli,  originating  not  only  in  lai-ge 
thi-ombosed  vessels,  but  also  in  small  veins  adjacent  to  insignificant  in- 
juries and  inflammatory  foci  (e.  g.,  fracture  of  the  fibula,  furuncle), 
are  much  more  frequent  and  are  usually  more  dangerous  than  are  arte- 
ii;il  emboli.  They  pass  from  the  vessel  into  the  right  heart,  thence  into 
the  pulmonary  arteries,  occluding  the  principal  artery  or  its  branches. 
Tf  the  principal  artery  or  one  of  its  large  branches  is  occluded,  marked 


DISEASES  OF   THE   BLOOD   AND   LYMPHATIC   VESSELS  691 

(lyspiid'H  (Icv'lops  suddenly,  the  heart  beeonies  rapid,  weak,  and  soon 
exhausted,  and  death  occurs.  If  one  of  Ihc  h'ss  iiiiporlant  l»iaiiches 
becomes  oeehided^ — this  occurs  especially  in  the  right  lower  \o\n — the 
symptoms  of  hiemorrhagic  infarct  soon  develop. 

In  rare  cases  an  embolus  nuiy  pass  through  a  patent  foramen  ovale 
into  the  general  circulation  (paradoxical  embolus)  or  an  embolus  in 
a  large  vein  may  be  carried  backward  (retrograde  embolism)  in  a 
direction  opposite  to  the  current,  when  there  is  venous  stasis  and  the 
pulse  wave  is  transmitted  to  the  blood  in  the  veins  (Ribbert). 

^Metastatic  lung  abscesses  may  be  caused  by  infected  emboli.  Emboli 
arising  from  inflammatory  foci  in  the  lungs  (especially  tuberculous 
foci)  ma,y  pass  into  the  general  circulation  and  frequently  produce 
infarct-shaped  foci  in  the  viscera. 

Diagnosis. — The  diagnosis  of  thrombosis  can  be  made  only  when  the 
large  vessels  are  involved.  Chronic  oedema  resulting  from  venous  throm- 
bosis may  be  easily  mistaken  for  o-dema  due  to  other  causes. 

Treatment. — Rest  in  bed  and  immobilization  with  elevation  of  the 
aflfected  i^art  should  be  maintained  for  many  weeks — for  at  least  three. 
These  measures  favor  the  contraction  or  organization  of  the  thrombus 
and  the  establishment  of  a  collateral  circulation.  If  the  oedema  per- 
sists, a  bandage  or  elastic  stocking  exerting  mild  compression  should  be 
worn.  Absolute  rest  is  the  best  protection  against  embolism,  especially 
against  pulmonary  embolism,  which  is  always  of  the  gravest  significance. 
Large  doses  of  morphin  are  often  indispensable  in  quieting  the  patient. 
Cardiac  stinnilants  should  not  be  given  unless  cardiac  weakness  becomes 
serious,  as  the  increased  force  of  the  heart  beat  may  easily  separate  and 
set  free  particles  of  a  thrombus. 

Sudden  death  from  pulmonary  embolism  is  a  constant  menace,  even 
when  convalescence  from  inflammatory  processes  adjacent  to  the  veins 
of  the  abdomen  and  pelvis  (especially  in  appendicitis  and  inflannnation 
of  the  adnexa  and  after  operations  performed  for  the  relief  of  the 
same)  is  well  advanced.  Improvement  of  the  general  condition  and  of 
the  heart  and  complete  rest  in  the  recumbent  position  are  the  only 
methods  by  which  this  serious  accident  can  be  prevented. 

Literature. — Grawitz.  Klinische  Pathologie  des  Blutes.  Berlin,  1902.  Die 
Blutplattchen,  p.  128. — v.  Schrotter.  Erkrankungen  der  Gefiisse.  Wien.  I'.iOl. — 
Ziegler.     Thrombose.     Eulenburgs  Realenzyklopadie,  3.  Aufl. 

(e)    LYMPHANGIECTASES 

Lymphangiectases  of  the  thoracic  duct  and  the  larger  lynq:)hatic 
vessels  occur  especially  as  the  result  of  the  pressure  of  tumors,  and  are 
of  importance  only  in  those  cases  in  which  they  rupture  into  the  pleural 
or  peritoneal  cavities,  causing  chylothorax  and  chylous  ascites. 


692       SURGICAL   DISEASES,   EXCLUDING  INFECTIONS   AND  TUMORS 

Causes  of  Lymphatic  Varices — Lymph-CEdema. — Varices  develop  in  the 
lymphatic  vessels  of  the  skin  and  subcutaneous  tissue  after  frec^uently 
recurring  or  continued  inflammations  followed  by  thrombosis  and  oblit- 
eration of  the  vessels  (in  habitual  erysipelas,  recurring  lymphangitis, 
and  invasion  of  the  lymphatic  vessels  by  the  filaria  sanguinis)  ;  occasion- 
ally after  extirpation  of  suppurating  inguinal  lymph  nodes ;  after  exten- 
sive crushing  injuj'ies  and  phlegmons.  Not  infrequently  dilatation  of 
lymphatic  vessels  resulting  from  inflammation  is  associated  with  pachy- 
dermia. If  the  cutaneous  lymphatics  are  involved,  the  skin  becomes 
swollen,  the  boundaries  of  the  swelling  being  indistinct,  and  covered 
with  small,  closely  set  vesicles  which  never  become  larger  than  a  pea. 
The  skin  is  also  filled  with  dilated,  tortuous  lymphatic  vessels.  If  pres- 
su*re  is  made  upon  the  swollen  area,  the  fluid,  as  in  cedema,  may  be 
forced  into  the  surrounding  tissues,  and  a  pit  which  slowly  disappears 
remains  when  the  pressure  is  removed. 

If  the  larger  vessels  in  the  subcutaneous  tissues  are  dilated,  tor- 
tuous cords  resembling  angleworms  may  be  seen.  The  skin  over  these 
is  covered  with  small  vesicles  and  presents  the  signs  common  to 
a  lymph-o?dema.  [The  characteristic  appearance  of  lymph-oedema 
is  seen  in  the  pigskinlike  changes  associated  with  carcinoma  of  the 
breast.  The  peculiar  appearance  of  the  skin  in  these  cases  is  due  to  a 
lymph-O'dema  following  occlusion  of  the  lymphatic  vessels  by  carci- 
noma cells.] 

Clinical  Course  and  Diagnosis. — The  growth  of  a  lymphangiectatic 
swelling  is  very  slow  or,  after  acute  inflammatory  processes,  intermit- 
tent. It  is  scarcely  possible  to  difl'erentiate  less  extensive  lymphangiec- 
tases  from  a  lymphangioma.  All  congenital  dilatations  of  lymphatic 
vessels  should  be  classified  with  lymphangiomas.  They  can  scarcely  be 
mistaken  for  varicose  veins,  as  the  bluish  color  of  the  skin  indicates  that 
the  dilated  vessels  contain  blood. 

Complications. — Inflammations  of  the  skin  and  lymphorrhcea  are 
common  wlien  tlie  lyiii])liaties  of  the  skin  and  subcutaneous  tissues  are 
involved.  A  scratch  or  an  insignificant  injury  may  rupture  a  lym{)h- 
vesicle,  from  which  is  discharged  large  (piantities  of  lymph.  ["  In  one 
case  of  lyiiiphangicctasis  involving  the  la])ia  majoi-a  in  which  a  fistula 
develo])ed,  Nieden  found  that  in  four  houi's  there  was  an  escape  of  one 
and  a  half  liters  of  a  milky,  slightly  yellowish  licpiid  containing  fat  and 
resciiihliiig  cliylc. " — Tillmanns'  "  Text-book  of  Surgery,"  Vol.  I,  p. 
544. J  The  discharge  of  lym|)h  may  conlinue  for  days  and  weeks  with- 
out impairing  the  general  condition  of  the  patient.  It,  however,  mac- 
erates the  skin  which  is  continually  bathed  by  it,  and  ])rovi(les  infection 
atria  foi-  ])lilegnionons  infiammations  and  erysipelas.  A  lymphoi-rluea 
is  fi-e(ju('n11y  followed  by  lymphangitis. 


DISEASES   OF   THE   PERIPHERAL   NERVES  693 

Treatment. — The  treatment  of  the  h^ss  extensive  lyniphangiectases 
limited  to  the  skin  and  subentaneons  tissues  is  the  same  as  that  em- 
ployed for  lymphangioma.  The  dilated  lymphatic  vessels  should  be 
excised.  Extensive  swellings  subside  gradually  under  the  pressure  of 
M-ell-applied  bandages  and  elevation  of  the  extremity.  If  there  is  a 
lymphorrhfpa,  dressings  of  oxid  of  zinc  ointment  should  be  applied  to 
protect  the  surrounding  skin.  Lymph  fistuloe  frequently  close  after 
repeated  cauterizations  with  silver  nitrate.  In  the  more  resistant  cases 
incision  and  tamponing  of  the  wound  with  iodoform  gauze  is  often 
necessary. 

Literature. — Fr.  Fischer.  Krankheiten  der  Lymphgefasse,  Lymphdri'isen  uiid 
Blutgefasse.     Deutsche  Chir.,  190L 


CHAPTER   V 

DISEASES    OF    THE   PERIPHERAI^    NERVES 

(a)  NEURALGIA 

Definition — True  and  Symptomatic  Neuralgia. — By  neuralgia  is  un- 
derstood a  disease  of  the  sensory  nerves,  the  chief  symptom  of  which 
is  pain.  It  may  occur  as  an  independent  affection  (true  neuralgia)  or 
be  merely  symptomatic  (symptomatic  or  secondary  neuralgia)  of  some 
local  or  general  lesion  influencing  the  nerves.  When  occurring  as  an  in- 
dependent affection,  no  pathological  changes  are  found  in  the  nerves. 

Characteristics  and  Symptoms. — The  most  important  characteristics 
of  neuralgia  are  intermittent  or  remittent  attacks  of  severe,  often  ago- 
nizing, pain  which  radiates  along  nerves,  nerve  trunks,  or  plexuses,  and 
subsides  completely  or  incompletely  after  lasting  for  a  few  minutes 
or  hours.  The  pain  may  recur  upon  the  slightest  provocation,  such  as 
pressure  upon  the  nerve  or  movement  on  the  part  of  the  patient. 

The  symptoms  which  usually  develop  in  middle  life  either  begin  sud- 
denly, reaching  their  maximum  intensity  early,  or  are  mild  in  the  begin- 
ning and  gradually  increase  in  severity.  Sometimes  the  pain  begins 
without  warning,  at  other  times  there  are  prodromata,  such  as  mild 
shooting  pain  and  tingling  sensations.  A  few  hours  or  days  may  inter- 
vene between  the  attacks.  Frequently,  when  the  attack  is  at  its  height, 
the  pain  is  no  longer  limited  to  the  nerve  primarily  involved,  but  radi- 
ates along  adjacent  nerve  trunks  (irradiation). 

Neuralgia  may  extend  over  days,  weeks,  months,  or  years.  The 
symptoms  may  disappear  and  not  recur,  or  they  may  extend  to  other 
branches  of  the  same  nerve  or  plexus.     Sometimes,  especially  in  tri- 


694       SURGICAL   DISEASES,    EXCLUDING   INFECTIONS   AND  TUMORS 

facial  neuralgia,  the  patients  are  scarcely  free  from  pain,  which  is  so 
severe  that  they  have  often  conniiitted  suicide. 

A  number  of  disturbances,  of  which  the  following  are  the  most  pro- 
nounced and  frequent,  follow  interference  with  nerve  function:  (1) 
Sensory  disturbances  (the  area  supplied  by  a  diseased  sensory  nerve  is 
often  hyperaesthetic,  more  rarely  anaesthetic)  ;  (2)  increase  of  glandular 
secretion  (epiphora,  increased  flow  of  saliva  and  sweat)  ;  (3)  blanching 
and  flushing  of  the  skin,  d'^pending-  upon  the  condition  of  the  vessels; 
(4)  reflex  fibrillary  muscular  twitchings  during  an  attack  (e.  g.,  twitch- 
ing of  the  facial  muscles  in  trifacial  neuralgia)  ;  (5)  trophic  disturb- 
ances, such  as  atrophy  of  the  skin,  fallin^y  out  of  the  hair,  tendency  to 
eczema,  and  the  development  of  herpes  (herpes  zoster  in  intercostal 
neuralgia) . 

The  general  condition  of  the  patient  suffers  when  the  neuralgia  lasts 
for  any  length  of  time.  Pain  deprives  the  patient  of  sleep,  and  in 
trifacial  neuralgia  the  taking  of  food  is  interfered  Avith,  as  the  move- 
ments of  the  jaws  frequently  incite  attacks  of  pain.  Psychic  changes 
(irritability,  melancholia)  develop  in  the  protracted  and  severe  cases. 

Causes  of  Neuralgia. — The  causes  of  neuralgia  are  general  and  local. 
Among  the  general  causes  are  a  neuropathic  temperament,  exhausting 
physical  labor,  mental  worry — all  of  which  are  frequently  associated 
with  strong  emotions  and  sexual  excesses,  lessened  bodily  resistance,  gen- 
eral weakness,  and  chronic  constipation  (in  trifacial  neuralgia,  Gus- 
senbauer)  ;  infectious  diseases  (malaria,  typhoid  fever,  smallpox,  in- 
fluenza) ;  and  toxic  agents,  such  as  lead,  copper,  mercury,  alcohol,  and 
nicotin.  Neuralgia  also  occurs  in  diabetes  mellitus,  being  secondary 
to  the  changes  in  metabolism.  The  local  causes  are  chilling  of  the  part 
involved;  crushing  and  laceration  of  nerve  trunks;  pressure  by  pene- 
trating foreign  bodies ;  traction  and  pressure  exerted  by  scar  tissue  upon 
the  surrounding  nerves;  pressure  upon  nerve  trunks  by  displaced  frag- 
ments of  bone,  aneurysms,  varicose  veins,  gummas,  and  tumors  (also 
amputation  neuromas)  ;  and,  finally,  inflammation  about  nerve  endings 
or  trunks,  such  as  periostitis  of  the  mandible,  suppuration  of  the  acces- 
sory sinuses  of  the  nose,  carious  teeth,  ulcers  of  the  mucous  membranes, 
tuberculosis  of  the  vcj-tebra,  sacrum,  and  ribs. 

Neuralgialike  pains  may  also  ho  associated  with  tumors  and  diseases 
of  the  central  nervous  system  (tumoi-s  at  the  base  of  the  brain  and  of 
the  spiiud  cord,  tabes  doj-salis,  syphilitic  meningitis,  multiple  sclerosis) 
(( )pi)enheini) . 

Nerves  Most  Commonly  Involved — Pain  Points  and  Diagnosis. — Neu- 
ralgia of  llic  trigeminal  nerve  is  the  most  common.  Then  follow  in 
order  of  frecpiency,  ncnn-algia  of  the  sciatic,  intercostal,  and  occipital 
nerves,  of  the  nerves  of  the  lumbar,  pudendo-ha^niorrhoidal  and  coc- 


DISEASES   OF   THE   TERIPHERAL   .\ERVES  695 

cviieal  plexuses,  and  of  the  extremities.  The  p(>enliaritics  in  the  onset, 
symptoms,  and  clinical  course  of  each  of  tliese  dilVerent  forms  belong 
to  the  province  of  special  surgery  and  nervous  diseases. 

In  making  a  diagnosis  of  neuralgia  it  is  important  to  note  that  the 
l);tin  eon-esponds  to  the  anatomical  distribution  of  the  nerve  involved, 
and  that  it  exteiuls  beyond  the  areas  supplied  by  the  n(M-ve  primai-ily 
involved  only  at  the  height  of  the  attack.  Certain  points,  the  so-called 
pdiii  points,  are  very  sensitive  to  pressure,  and  an  attack  may  be  pro- 
voked by  making  pressure  at  these  points.  Such  pain  points  are  found 
where  the  nerve  trunks  or  branches  leave  a  bony  canal,  or  where  they 
can  be  easily  pressed  against  some  resistant  band ;  for  example,  in  neu- 
ralgia of  the  sciatic  nerve  at  the  border  of  the  gluteus  maximus  muscle, 
in  the  middle  of  the  popliteal  fossa  and  below  the  head  of  the  fibula, 
in  neuralgia  of  the  supraorbital  nerve  at  the  supraorbital  notch,  and  of 
the  infraorbital  nerve  at  the  corresponding  foramen. 

The  local  or  general  causes  of  the  neuralgia  should  always  be  looked 
for,  as  the  treatment  which  should  be  instituted  depends  upon  the  cause. 
A  good  example  of  this  is  malarial  neuralgia  (which  subsides  under 
c|uinin,  or  sciatic  neuralgia  (which  often  gives  a  clew  to  a  pelvic  tu- 
mor, or  tuberculosis  of  the  spine  [perhaps  still  curable],  or  a  tumor 
of  the  rectum).  Bilateral  neuralgias  involving  synnnetrical  nerves  al- 
ways suggest  some  central  lesion,  such  as  a  tumor  of  the  skull  or  of 
the  base  of  brain ;  an  intercostal  neuralgia  suggests  a  tumor  of  the  cord 
or  a  tuberculous  spondylitis.  The  symptoms  may  be  unilateral  in  these 
lesions,  and  then  the  diagnosis  is  dii'ticult  if  there  are  no  other  symp- 
toms (cf.  psamomma  of  the  dura  illustrated  in  Chapter  VI,  Part  II, 
which  caused  a  trifacial  neuralgia,  the  ganglia  being  extirpated  under 
the  wrong  diagnosis).  Neuralgia  may  be  mistaken  for  the  false  neu- 
ralgia occurring  in  hysterical  patients,  attacks  in  whom  are  generally 
induced  by  some  psychic  disturbance.  It  may  also  be  mistaken  for 
neuritis  when  a  careful  examination  is  not  made. 

Treatment. — The  treatment  of  neuralgia  is  generally  successful  if  the 
cause  can  be  removed.  This  is  less  difficult  w'hen  the  cause  is  local  and 
peripheral  than  when  it  is  general  or  central.  As  a  rule,  the  neuralgia 
disappears  when  scar  tissue  pressing  upon  the  nerves,  the  tumor,  frag- 
ment of  bone,  foreign  body,  etc.,  is  removed  and  the  inflammation  sub- 
sides. Genei'al  diseases  should  receive  appropriate  treatment,  a  hygienic 
mode  of  life  should  be  adopted,  the  general  condition  of  the  patient 
improved,  and  constipation  corrected. 

If  no  cause  can  be  found,  or  if  the  general  or  local  cause  has  been 
removed  without  success,  the  remedies  and  procedures  used  in  internal 
medicine  should  be  tried  (vide  Edinger).  Only  the  most  important  of 
these   Avill   be    mentioned.      Quinin    (not   in    malarial    neuralgia    only), 


696       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND  TUMORS 

arsenic  in  the  form  of  Fowler's  solution,  potassium  bromid,  aconite, 
aspirin,  and  pyramidon  are  especially  to  be  recommended.  Local  appli- 
cations of  heat  (warm  compresses,  poultices,  hot-water  bags  and  bottles) 
and  electricity,  both  the  galvanic  and  faradic  current,  may  be  tried. 
Sometimes  weak  solutions  of  cocain,  eucain,  or  Schleich's  solution  are 
injected  about  the  affected  nerve  trunks  to  produce  transitory  anii'S- 
thesia  or  a  one  per  cent  solution  of  osmic  acid  is  injected  into  the  nerve 
to  produce  a  degeneration  of  its  fibers.  Injections  of  alcohol  along  the 
tract  of  the  nerve  have  recently  been  employed  with  some  success.  In 
severe  cases  morphin  is  required,  but  operative  treatment  should  be 
instituted  before  the  patient  becomes  accustomed  to  large  doses  and 
contracts  the  morphin  habit. 

,  If  all  these  different  methods  have  been  tried  without  success;  or  if 
the  general  condition  of  the  patient  rapidly  becomes  worse,  as  the  attacks 
recur  more  frequently,  surgical  treatment  is  indicated.  Results  can  be 
promised  only  when  there  is  no  central  cause,  for  in  the  latter  case  the 
pain  persists  even  after  removal  of  the  nerve. 

Neurotomy,  Neurectomy,  and  Nerve  Stretching. — Neurectomy  (in- 
troduced by  Abernethy,  1793)  soon  replaced  neurotomy  (first  per- 
formed by  Schlichting  in  1748).  The  results  following  the  latter  were 
only  temporary,  as  the  sensory  nerves  rapidly  regenerated.  Even  after 
neurectomy  there  is  danger  of  the  continuity  of  the  nerve  being  rees- 
tablished unless  long  pieces  are  removed.  Nerve  extraction  devised  by 
Thiersch  (1889)  is  more  reliable  than  either  of  the  methods  above  men- 
tioned, and  should  be  tried  in  trifacial  neuralgia  before  the  removal 
of  the  ganglion  is  considered.  In  this  method  the  nerve  trunk  is  ex- 
posed at  a  suitable  point,  then  grasped  with  forceps  and  twisted  until 
all  its  connections  are  gradually  torn.  If  patience  is  exercised,  sections 
of  the  nerve  from  10  to  20  cm.  in  length  may  easily  be  removed. 

Even  after  extraction  recurrences  are  frequent,  especially  in  tri- 
facial neuralgia.  These  recurrences  are  due  to  the  regeneration  of  the 
nerve  from  central  fibers  which  were  not  accessible  M'hen  the  nerve 
extraction  was  perf(n-med.  Hartley  and  Krause  (1892)  performed  a 
more  radical  operation  in  cases  of  this  character,  removing  the  Gasser- 
ian  ganglion  (literature  by  Lexer  and  Tiirk).  Shortly  before  this  Ilors- 
ley  had  cut  the  sensory  root  behind  the  ganglion. 

In  the  treatment  of  persistent  neui-nlgias  of  the  mixed  nerves  supply- 
ing the  trunk  and  extremities,  it  may  be  necessary  to  perform  a  laminec- 
tomy, and  after  incising  the  dura  mater  to  resect  the  posterior  or  sensory 
roots  of  the  nerves  involved  (Chipault  and  others).  In  cases  in  which 
there  are  also  muscular  spasms  it  is  not  necessary  to  open  the  dura 
mater,  as  both  roots  may  be  resected  where  they  join  to  form  the  nerve 
Ix'Toic  it  divides  into  its  anterior  and  posterior  divisions  (cf.  Schede). 


DISEASES   OF  THE   PERIPHERAL   NERVES  697 

Nerve  siretching  was  first  practiced  by  Billroth  in  1869,  then  by 
NiissbaUin  in  1872,  and  was  especially  reconnnended  l)y  the  latter. 

It  was  first  employed  for  the  treatment  of  epileptiform  attacks  fol- 
lowing contusions  of  nerves.  Gartner  (1872)  was  the  first  to  employ 
this  method  for  the  treatment  of  neuralgia  involving  the  brachial  plexus. 
It  was  soon  tried  in  a  number  of  different  diseases ;  for  example,  the 
sciatic  nerves  were  stretched  for  the  relief  of  tabes  dorsalis  (Langen- 
buch),  the  facial  nerve  for  convulsive  tic,  the  spinal  accessory  for  con- 
vulsive wryneck,  the  fifth  cranial  nerve  for  trifacial  neuralgia.  Finally 
the  nerves  were  even  stretched  in  tetanus  (Vogt  and  others).  The  re- 
sults which  had  been  expected  were  not  obtained,  and  the  method  was 
finally  abandoned. 

According  to  Schede,  however,  nerve  stretching  is  to  be  recom- 
mended not  only  in  the  treatment  of  resistant  neuralgias  of  mixed 
nerves  and  painful  muscular  spasms,  but  also  in  the  treatment  of  nerve 
changes  following  neuritis.  AVhile  a  complete  and  permanent  cure  can- 
not be  promised,  considerable  improvement  may  be  expected.  In  spinal 
affections  it  has  no  effect  upon  the  course  of  the  disease,  and  in  the  treat- 
ment of  neuralgias  of  sensory  nerves,  nerve  extraction  has  been  used 
in  its  place  (Schede)  for  a  long  time. 

In  performing  the  operation  of  nerve  stretching  the  nerve  is  ex- 
posed at  the  point  desired,  is  isolated  by  blunt  dissection,  is  then  grasped 
between  the  thumb  and  index  finger  or  by  suitable  tractors,  and  stretched 
both  Avays  until  it  has  been  plainly  lengthened. 

The  benefits  derived  from  nerve  stretching  are  due  to  the  lessened 
conductivity  following  the  trauma,  to  the  degenerative  and  regenera- 
tive changes  occurring  in  the  nerve  following  the  operation,  and  to 
the  separation  of  the  nerve  from  the  cicatricial  tissue  which  may  sur- 
round it. 

The  best  results  have  been  obtained  in  the  treatment  of  sciatica. 
Bloodless  stretching  of  the  sciatic  nerve  has  also  been  attempted.  In 
the  latter  procedure  the  ijatient  is  anaesthetized  and  the  straightened 
extremity  is  flexed  at  the  hip  joint  until  the  leg  comes  in  contact  with 
the  face.  The  extremity  is  then  maintained  in  this  position  for  five 
minutes. 

(b)  NEURITIS 

Definition. — Neuritis  is  an  acute  or  chronic,  serous  or  seropurulent 
inflammation  of  the  perineurium  and  interstitial  tissue  of  nerves,  result- 
ing in  the  degeneration  of  the  fibers  with  secondary  proliferation  of  the 
connective  tissues  of  the  nerve.  The  part  of  the  nerve  affected  presents 
a  fusiform  swelling  and  is  reddened,  as  a  result  of  the  inflammatory 
infiltration  and  hyperaemia.  After  the  development  and  induration  of 
45 


698      SURGICAL   DISEASES,   EXCLUDING    INFECTIONS   AND  TUMORS 

new  connective  tissue  the  nerve  becomes  hard,  irregular,  and  noduhir, 
and  firmly  adherent  to  adjacent  structures. 

Etiology. — The  most  conniion  causes  of  neuritis  are  injuries  of  vari- 
ous kinds,  and  toxaemias  associated  with  infectious  diseases,  chronic  poi- 
sonings, and  constitutional  diseases.  The  most  common  injuries  affecting 
nerves  are  lacerations  and  contusions,  repeated  blows  or  long-continued 
pressure  on  nerve  trunks  received  in  certain  occupations  (occupation 
neuritis)  or  while  using  a  crutch  (crutch  palsy),  the  pressure  of  frag- 
ments of  fractured  bones  and  ends  of  dislocated  bones,  foreign  bodies 
(such  as  a  fragment  of  glass,  point  of  a  knife,  a  bullet),  tumors,  cer- 
vical ribs,  etc.  In  open  injuries  involving  the  nerves  and  in  cases  in 
which  pyogenic,  tuberculous,  or  gummatous  lesions  have  extended  from 
bones  or  joints  and  have  involved  the  nerves,  bacterio-toxic  and  mechan- 
ical causes  are  combined.  Neuritis  may  develop  during  the  course  of 
or  subsequent  to  a  number  of  infectious  diseases,  such  as  general  pyogenic 
infections,  especially  of  puerperal  origin,  typhoid  fever,  diphtheria, 
syphilis,  etc.,  and  in  chronic  poisoning  due  to  lead,  arsenic,  alcohol,  and 
nicotin.  Cold,  rheumatism,  gout,  diabetes  mellitus,  leukemia,  and  arte- 
riosclerosis are  also  to  be  considered  as  causes. 

The  inflammation  following  local  causes  gradually  extends  in  the 
form  of  an  ascending  and  descending  neuritis  toward  the  cord  and 
periphery.  When  the  cause  is  general,  not  infrequently  a  number  of 
different  nerves  are  involved  (polyneuritis).  In  chronic  alcoholism, 
lead  and  arsenic  poisoning,  paralysis  of  the  extensors  of  the  hands  and 
feet,  more  rarely  of  the  flexors,  develops,  while  in  diphtheria  {vide  p. 
351)   ;iny  nerve  may  be  attacked. 

Symptoms. — Acute  neuritis  may  begin  with  chills  and  fever.  Pain 
of  a  boring,  tearing  character,  localized  in  the  nerve  primarily  afl^ected, 
which  is  increased  by  movements  and  pressure,  is  the  most  important 
symptom.  Symptoms  of  irritation  of  the  sensory  and  motor  nerves 
consisting  of  parjpsthesia,  hypera'sthesia,  and  contractures  follow  the 
pain.  As  the  Icsicm  advances  the  nei-ves  no  longer  conduct  impulses, 
and  then  the  reflexes  disappear;  ana'slhesias,  trophic  disturbances,  pal- 
sies, imd  hitcr  flaccid  paralyses  with  inuscular  atrophy  and  the  reaction 
of  degeneration  develop. 

Chronic  neuritis,  nnless  it  develo])s  from  an  acute  form,  begins  more 
insidiously.  The  paiii  in  elironic  neuritis  is  less  severe,  and  nodular 
thickening  may  develop  along  the  nerve  involved  (neuritis  nodosa). 

Acute  cases  of  neuritis  may  subside  after  a  few  weeks,  the  nerve 
fibers  regenei'ating.  In  chronic  neuritis,  functional  disturbances  which 
resist   treatinent  oi-  become  permanent  develop  more  frequently. 

Diagnosis. — It  is  not  always  possible  to  make  a  diagnosis  between 
neuritis  and  neuralgia.    The  character  of  the  pain  is  of  diagnostic  value. 


DISEASES  OF   JOINTS  699 

In  neuritis  it  is  continuous,  while  in  neuralgia  it  occurs  at  intervals. 
In  neuralgia  the  tenderness  is  limited  to  certain  points  (pain  points,  p. 
695),  while  in  neuritis  the  pain  extends  along  the  entire  nerve,  which 
is  often  perceptibly  thickened.  Finally  the  marked  sensory,  motor,  and 
trophic  disturbances  which  develop  rapidly  in  neuritis  are  W'anting  in 
neuralgia.  It  may  be  difficult  at  times  to  differentiate  multiple  fibromas 
of  nerve  trunks  from  the  nodular  form  of  neuritis.  The  former,  however, 
are  usually  associated  with  soft  fibromas  of  the  skin  and  pigmented  areas, 
and  besides  there  is  no  interference  with  nerve  conduction. 

Treatment. — In  the  treatment  an  attempt  should  be  made  to  remove 
the  mechanical  or  inflammatory  cause,  and  then  to  innnobilize  the  ex- 
tremity involved.  Morphin,  sodium  salicylate,  salol,  and  aspirin  are 
the  drugs  usually  recommended.  [INlorphin  should  be  used  sparingly, 
however,  as  there  is  always  the  danger  that  the  patient  may  contract 
the  habit.]  In  chronic  cases  an  attempt  should  be  made  to  favor  regen- 
erative processes  by  massage,  electricity  and  baths.  Contractures  and 
paralyses  should  receive  appropriate  treatment. 

If  an  attempt  is  made  to  remove  a  local  cause,  such  as  a  foreign 
body  or  cicatricial  tissue,  the  nerve  should  be  exposed  for  some  dis- 
tance, the  adhesions  between  adjacent  tissues  and  the  perineurium  dis- 
sected away,  and  the  nerve  stretched.  Nerve  stretching  in  chronic  cases 
has  a  favorable  action.  It  not  only  frees  the  nerve  from  adhesions,  but 
stimulates  regenerative  processes.  ' 

Literature. — Chipault  et  Demoulin.  La  resection  intradurale  ties  racines  medul- 
laires  post.  Gaz.  des  hopitaux,  1895,  No.  95. — Edinger.  Behandlung  der  Neuralgic. 
Handb.  der  Therapie  von  Penzoldt  u.  Stintzing,  Bd.  5,  Part  II,  p.  553. — Th.  KoUiker. 
Die  Verletziingen  und  chir.  Erkrankungen  der  periph.  Nerven.  Deutsche  Chir.,  1890. — 
Fedor  Krause.  Die  Neuralgic  des  Trigeminus.  Leipzig,  1896. — Lexer.  Zur  Operation 
des  Ganglion  Gasseri  nach  Erfahrungen  an  15  Fallen  nebst  Zusammenstellung  der 
ausgefijhrten  Ganglionexstirpationen  von  W.  Tiirk.  Arch.  f.  klin.  Chir.,  Bd.  65,  1902, 
p.  843. — Oppenheim.  Lehrbuch  der  Nervenkrankheiten.  Berlin,  1904. — Schede. 
Chirurgie  der  peripheren  Nerven  und  des  Riickenmarkes.  Handb.  d.  Therap.  von 
Penzoldt  u.  Stintzing,  Bd.  5,  Part  II,  p.  738. — Thiersch.  Ueber  Extraktion  von  Nerven. 
Chir.  Kongr.-Verhandl.,  1889,  I,  p.  44. 


CHAPTER    VI 

DISEASES   OP    JOINTS 

(a)  DISLOCATIONS   AND    SUBLUXATIONS 

Dislocations  and  subluxations  may  be  congenital  or  acquired.  Of 
congenital  dislocations,  those  of  the  hip  are  the  most  frequent.  This 
malformation  is  more  frequently  unilateral  than  bilateral,  and  is  more 


700       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND   TUMORS 

cominoii  in  girls  than  in  boys.  Congenital  dislocations  of  the  shoulder, 
knee,  and  elbow  joints  are  infrequent,  as  are  also  those  of  the  head  of 
the  radius,  of  the  external  malleolus,  of  the  wrist,  of  the  fingers,  of  the 
patella  and  clavicle. 

Congenital  Dislocation. — Theories  as  to  Causes. — The  causes  of  con- 
genital, frequently  also  of  acciuired  dislocations,  are  not  clear.  There 
are  a  number  of  theories  as  to  the  cause  of  congenital  dislocation  of  the 
hip.  [It  is  probably  due  in  some  cases  to  malposition  of  the  foetus  in 
the  uterus,  or  to  some  irregularity  in  the  shape  of  the  uterus.  J  If  in 
the  beginning  of  pregnancy  there  is  an  insufficient  amount  of  anmiotic 
fluid,  the  .walls  of  the  uterus  will  be  closely  applied  to  the  fretus,  its 
thighs  Avill  be  forcibly  flexed  and  adducted,  and  the  head  of  the  femur 
will  be  forced  out  of  the  acetabulum  (Hoffa).  Abnormal  amniotic 
bands  may  interfere  with  the  normal  development  of  any  of  the  other 
joints. 

Symptoms  and  Signs  of  Congenital  Dislocations. — The  deformity 
resulting  from  a  congenital  dislocation  may  be  more  or  less  marked  at 
birth.  The  symptoms,  however,  as  is  usually  the  case  in  congenital 
dislocations  of  the  hip,  may  not  be  noted  until  the  child  begins  to 
walk. 

[Patients  with  a  congenital  dislocation  of  the  hip  have  a  peculiar 
waddling  gait,  which  becomes  very  pronounced  when  but  one  side  is 
afl^ected.]  The  signs  common  to  the  acquired  are  found  in  congenital 
dislocations,  but  the  head  of  the  femur  is  usually  freely  movable,  and 
movements  cause  no  pain.  In  fat  children  the  head  of  the  femur  can- 
not be  palpated  unless  there  is  considerable  displacement.  X-ray  pic- 
tures should  be  taken.  The  most  accurate  diagnosis  can  be  made  in 
this  way. 

Jicduetion  of  Dislocation. — Reduction  of  the  dislocation  is,  as  a  rule, 
difficult  only  in  the  old  cases  with  contracted  soft  tissues,  and  in  those 
cases  with  secondary  joint  changes  resembling  those  of  arthritis  defor- 
mans. After  reducti(m,  the  parts  must  be  maintained  in  position  for 
a  long  time  by  proper-ly  applied  bandages.  If  the  dislocation  cannot 
be  reduced  after  the  shortened  nniscles  have  been  stretched  and  length- 
ened, an  operation  in  whicli  the  joint  is  exposed  and  the  obstacles  to 
reduction  are  removed  should  be  performed. 

Prognosis.— Usually  the  functional  results  following  bloodless  reduc- 
tion are  better  than  those  obtained  by  operative  procedures.  The  latter 
should  be  eitiploycvl  only  in  bad  cases,  aftei-  attempts  at  I'eduction  by 
llie  hluodless  iiictliod  have  failed.  Thei'e  is  always  danger  of  anchylosis 
al'ter   rediielioii   Ity  the  ()[)eii   method. 

Acquired  Dislocation — Pathological  and  Traumatic. — Accjuired  dislo- 
cations which  are  secondary  to  some  disease  of  the  joints  are  known  as 


DISEASES  OF   JOINTS  701 

spontaneous  or  pathological  dislocations,  and  are  differentiated  from  the 
traumatic,  which  are  produced  by  force. 

Causes. — Pathological  dislocations  may  follow  intlanniiation  of  the 
joints  in  which  the  capsule  is  distended  by  a  large  exudate  or  the  articu- 
lar surfaces,  forming  the  joint,  and  the  capsule  are  destroyed.  Dislo- 
cations following  distention  of  the  capsule  are  known  as  dislention  dis- 
locations; those  following  destructive  changes  in  the  joint  as  destruction 
dislocations. 

Pathological  dislocations  may  follow  deformities  due  to  defects  in 
or  shoi-tening  of  neighboring  bones;  for  example,  dislocation  of  the 
head  of  the  ulna  after  resection  or  pathological  shortening  of  the 
radius,  outward  and  upward  dislocation  of  the  head  of  the  fibula  after 
necrosis  of  the  tibia.  Dislocations  frequently  follow  paralysis  of  the 
muscles  surrounding  a  joint.  If  all  the  muscles  are  paralyzed,  the  weight 
of  the  entire  extremity  is  thrown  upon  the  capsule  of  the  joint,  which 
becomes  stretched  and  lax.  The  articular  surfaces  then  fall  away  from 
each  other  and  a  paralytic  flail  joint  develops.  A  dislocation  of  this 
kind  may  be  easily  reduced,  but  recurs  as  soon  as  the  pressure  exerted 
by  the  hands  or  some  special  apparatus  is  removed.  The  diagnosis  of 
a  dislocation  of  this  character  is  easily  made,  as  the  soft  tissues  are 
atrophic  and  the  exact  positions  of  the  articular  ends  of  the  bone  can 
easily  be  determined.  A  dislocation  may  occur,  even  if  only  a  few  of 
the  muscles  surrounding  a  joint  are  paralyzed,  as  the  antagonistic  mus- 
cles which  are  not  paralyzed  gradually  separate  the  articular  ends  of 
the  bone  and  but  little  force  is  required  to  complete  the  dislocation. 
For  example,  when  the  abductors  and  rotators  of  the  thigh  are  para- 
lyzed, the  adductors  produce  a  dislocation  backward.  If  the  conditions 
are  reversed  a  dislocation  forward  occurs. 

Symptoms  and  Diagnosis. — The  symptoms  and  functional  disturb- 
ances following  pathological  dislocations  differ,  depending  upon  the 
cause.  The  diagnosis  is  based  upon  the  abnormal  position  of  the  articu- 
lar ends  of  the  bones  and  upon  the  symptoms  of  the  disease  of  the  joints. 

Treatment. — Reduction  of  the  dislocation  and  treatment  of  the  ac- 
companying inflammation  of  the  joint  or  bones  shouKl  be  combined.  If 
the  dislocation  follows  inflammation  of  the  joint  or  of  the  articular 
ends  of  the  bones,  the  reduction  should  be  made  by  gradual  extension 
rather  than  by  the  manipulations  used  in  the  reduction  of  traumatic 
dislocations.  If  the  dislocation  is  not  recent,  it  may  be  necessary  to 
reduce  it  by  the  open  method.  Paralytic  contractures  should  receive 
appropriate  treatment.  Resection  of  the  ends  of  the  bones  is  indicated 
when  there  is  anchylosis  and  in  destruction  dislocations.  The  tendons 
should  be  shortened  and  some  apparatus  worn  after  the  reduction  of 
paralytic  dislocations. 


702       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 

(b)  CONTRACTURES  AND   ANCHYLOSIS 

By  contracture,  strictly  speaking,  is  understood  the  results  of  mus- 
cular contraction — that  is,  the  approximation  of  two  neighboring  parts 
of  the  body.  By  the  term  as  it  is  employed  to-day  is  understood,  how- 
ever, not  only  the  condition  produced  by  active  muscular  contractions, 
but  also  the  faulty  positions  in  which  joints  may  become  more  or  less 
fixed  as  the  result  of  the  contraction  and  shortening  of  the  soft  tissues 
surrounding  them  or  by  the  permanent  contraction  of  a  group  of 
muscles. 

Depending  upon  the  position  in  which  the  joints  become  fixed,  con- 
tractures in  the  position  of  flexion,  extension,  adduction,  abduction, 
rotation,  pronation,  and  supination  are  described.  If  the  contracture 
is  marked  (most  often  in  flexion)  an  acute  angle  may  be  formed  between 
the  approximated  parts;  if  less  marked,  an  obtuse  angle. 

The  joint  surfaces  may  maintain  their  anatomical  relations  or  be 
partially  or  completely  separated.  In  the  former  case  they  may  be 
united  by  fibrous  bands  or  masses  of  bone  (fibrous  or  bony  anchylosis). 

Congenital  Contractures. — Some  congenital  contractures  are  due  to 
failures  of  development;  they  are  then  frecjuently  associated  with  bony 
defects.  Some  are  due  to  pressure  of  the  uterus  upon  the  foetus,  when 
there  is  insufficient  amniotic  fluid,  or  to  constriction  by  the  cord  and 
amniotic  bands.  They  occur  occasionally  as  flexion  contractures  of  the 
hip,  of  the  knee,  and  of  the  wrist,  and  not  infrequently  of  the  little 
finger.  Congenital  contractures  occur  frequently  in  the  foot  in  the 
form  of  different  varieties  of  club-foot.  Talipes  varus  is  most  common, 
while  flat-foot  (by  pronation),  talipes  equinus,  and  calcaneus  are  rarer. 
Congenital  spastic  contractures  due  to  congenital  defects  of  the  nervous 
system  or  to  injuries  of  the  cerebrum  during  birth  also  occur. 

In  all  congenital  contractures  malpositions  develop  as  the  muscles, 
fascia,  and  ligaments  contract  and  the  mobility  of  the  joints  is  de- 
creased. 

Acquired  contractures  are  of  dermatogenous,  desmogenous,  myoge- 
nous, neurogenous,  and  arthrogenous  origin  (Iloffa). 

Dermatogenous'  Contractures. — Dermatogenous  contractures  are  pro- 
duced by  scars  in  the  skin,  and  may  be  overcome  by  excising  the  scar 
and  uniting  the  edges  of  the  resulting  defect  or  covering  it  with  skin 
grafts. 

Desmogenous  Contractures. — Desmogenous  contractures  are  produced 
by  deep  scars  (for  exami)le,  after  ])urns,  necrosis  of  tendons  and  fascia 
following  suppuration  and  injuries),  or  in  the  hand  by  overgrowth  and 
contrjiction  of  the  palmar  fascia.  In  the  latter  the  contracture  begins, 
and  is  most  pronounced  in  the  ring  and  little  fingers.     As  the  contrac- 


DISEASES   OF   JOL\TS  703 

tnres  advance  the  fingers  involved  become  flexed  ( Dupiiytren 's  con- 
tracture).   The  thumb  is  more  rarely  involved. 

Excision  of  the  sear  tissue,  in  Dupuytren's  contracture  of  the  altered 
palmar  fascia,  is  the  most  efficient  treatment.  The  portion  of  the  skin 
which  is  sometimes  involved  in  the  scarlike  tissue  should  also  be  excised. 
After  removal  of  the  scar  and  correction  of  the  contracture,  the  defect 
should  be  covered  M'ith  pedunculated  skin  flaps  or  skin  grafts  (Lexer). 
It  is  most  difficult  to  correct  contractures  following  phlegmonous  in- 
flammation of  the  tendon  sheaths  (tendogenous  contractures).  When 
the  tendons  are  destroyed  forcible  extension  with  immobilization  in 
the  corrected  position,  and  even  excision  of  the  scar  with  skin  grafting, 
freeing  of  the  tendons  from  surrounding  scar  tissue,  and  lengthening 
of  the  same  give  but  temporary  results.  Adhesions  soon  form  again, 
and  the  prognosis  as  regards  function  is  hopeless. 

Myogenous  Contractures. — IMyogenous  contractures  are  due  to  short- 
ening of  the  nuiscle  fibers,  which  may  be  the  result  of  certain  forms 
of  atrophy,  of  injury,  and  of  inflannnation  of  muscles.  If  an  extrem- 
ity is  held  in  one  position  for  a  long  time,  the  points  of  origin  and  in- 
sertion of  the  muscles  become  approximated,  and  finally  the  muscles 
become  adapted  to  their  new  conditions.  These  contractures  develop 
in  certain  occupations  (habit  contractures  with  flexion  of  the  fingers 
in  cabmen  and  handicraftsmen,  adduction  and  flexion  of  the  thigh  in 
patients  confined  to  bed  for  a  long  time),  when  an  extremity  is  inten- 
tionally held  in  a  certain  position  (for,  example,  when  the  foot  of  a 
shortened  extremity  is  held  in  the  position  of  talipes  equinus),  and 
finally  when  an  extremity  is  innnobilized  in  a  definite  position  for  a 
long  time  (pronation  and  supination,  flexion  of  the  forearm,  flexion 
of  the  foot,  flexion  of  the  thigh  when  elevated  after  amputation)  or 
when  the  bed  clothes  are  allowed  to  exert  pressure  for  some  time  upon 
the  anterior  part  of  the  feet  of  very  sick  patients.  The  weight  of  the 
foot  also  contributes  to  the  development  of  the  last  type  of  contractures. 

IMyogenous  contractures  are  frequently  caused  by  diseases  and  in- 
flammation of  the  muscles.  In  the  beginning  the  muscles  involved  are 
contracted  and  held  rigid,  as  extension  causes  pain.  The  best-known 
example  of  this  condition  is  the  so-called  rheumatic  wryneck,  which 
often  quickly  subsides  after  massage.  In  suppurative  inflammation,  in 
tuberculosis  and  syphilis  of  the  muscles,  in  fibrous  myositis,  in  ischamiia, 
and  inflammation  following  contusions  and  lacerations  of  the  muscle 
fibers  cicatricial  tissue  forms,  which  later  contracts,  producing  distress- 
ing and  often  unsightly  deformities.  The  best  known  of  these  are  con- 
tractures of  the  fingers  after  phlegmonous  inflammation  of  the  muscles 
upon  the  anterior  surface  of  the  forearm,  flexion  contracture  of  the 
thigh  in  tuberculous  spondylitis  following  cicatricial  contraction  of  the 


704       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND   TUMORS 

ilio-psoas  nuiscle,  claw  hand  after  ischai'mic  paralysis  of  the  muscles 
of  the  forearm  (Fig.  243),  cicatricial  wryneck  following  laceration  of 
the  sterno-cleiclo-mastoid  muscle  during  labor  or  secondary  to  fibrous 
myositis. 

In  the  milder  cases  marked  improvement  follows  massage  and  passive 
motion.  In  the  severer  cases,  if  results  are  not  obtained  by  forcible 
correction  under  general  anaesthesia,  division,  lengthening  and  trans- 
plantation of  tendons  may  be  tried.  Sometimes  relief  follows  resection 
of  the  bones.  [A  number  of  cases  have  been  reported  lately  in  which 
ischaemic  contractures  have  been  greatly  improved  by  resecting  the 
bones.  Kesection  of  the  bones  of  course  produces  a  relative  lengthen- 
ing of  the  shortened  tendons.]  When  muscles  are  inflamed  an  attempt 
should  be  made  to  prevent  contractures  by  dressing  and  maintaining 
the  parts  involved  in  a  correct  position.  According  to  Hildebrand  an 
attempt  should  be  made  in  ischa?mic  contractures  to  dissect  the  nerves 
free  from  scar  tissue  and  to  place  them  where  they  will  no  longer  be 
compressed  by  it  {vide  p.  656). 

Neurogenous  Contractures. — Neurogenous  contractures  are  often  ac- 
companied by  shortening  of  the  muscles,  but  the  principal  lesion  is  in 
the  nervous  system.  Reflex,  spastic,  and  'paralytic  forms  of  neuroge- 
nous contractures  are  described.  Reflex  contractures,  due  to  irritation 
of  sensory  nerves,  may  occur  in  almost  any  painful  lesion,  and  are  fre- 
quently the  first  symptom.  In  arthritis  the  joint  assumes  the  least  pain- 
ful position,  and  is  maintained  in  it  by  muscular  contraction.  In  order 
to  prevent  pain  the  anterior  abdominal  wall  becomes  boardlike  and  is  held 
rigid,  and  abdominal  respiration  is  suspended  in  the  beginning  of  acute 
peritonitis;  the  head  is  held  rigid  in  acute  suppurative  inflammation 
involving  the  side  of  the  neck;  and  the  jaws  are  held  closed  when 
phlegmonous  inflammation  attacks  the  muscles  of  mastication  or  the 
tissues  surrounding  them.  A  painful,  immobile  flat-foot  is  an  example 
of  a  reflex  contracture.  Sometimes  foreign  bodies  situated  upon  nerves 
or  scar  tissue  pressing  upon  them  cause  changes  which  result  in  con- 
tractures. 

These  contractures  usually  subside  when  the  cause  is  removed.  If 
the  reflex  contracture  continues  for  some  time,  the  muscles  become 
shortened  and  contracted,  and  the  treatment  described  above  for  myoge- 
nous contractures  nnist  then  be  employed.  I'ure  reflex  contractures  may 
be  easily  coi-rected  under  anaesthesia.  Recurrences  should  be  prevented 
by  immobilizing  the  parts  in  a  proper  position. 

The  spaslic  foi-iiis  arc  due  to  abnormal  iimervation  or  to  a  patho- 
logical irritation  of  a  motor  nerve  (Iloffa).  They  may  be  unilateral 
or  bilateral  and  are  almost  always  of  central  origin — that  is,  they  follow 
a  nuinhi'i-  of  (lin'i'i'ciit  lesions  of  the  brain  and  cord  (cerebral  tumors  and 


DISEASES   OF   JOINTS  705 

ha'niorrhafjes,  imiltiplo  sclerosis,  hydrocephalus,  compression  myelitis, 
sclerosis  of  the  cord,  chronic  meningitis,  hysteria,  etc.).  Congenital 
spastic  contractures  are  due  to  defects  or  birth  injuries  of  the  cere- 
brum. [Spastic  contractures  of  the  fingers,  known  as  "writer's  cramp, 
which  occurs  in  bookkeepers  and  stenographers,  is  a  neurosis.]  The  mus- 
cles are  in  a  state  of  pathological  contraction,  but  are  weak,  and  for 
this  reason  a  spastic  is  differentiated  from  a  flaccid  paralysis.  The 
muscles  feel  hard  and  rigid,  can  be  extended  only  with  difficulty  by 
passive  motion,  and  return  to  the  contracted  position  as  soon  as  the 
pressure  is  released.  The  tendon  reflexes  are  exaggerated.  In  con- 
genital spastic  contractures  frequently  only  the  legs  are  involved,  and 
especially  the  flexor  and  adductor  nniscles.  As  a  result  of  the  talipes 
equinus,  of  flexion  of  the  knee  and  hip  joints  and  adduction  of  the 
thigh,  the  gait  is  awkward.  The  adductors  become  stronger  than  the 
abductors,  and  a  peculiar,  characteristic,  cross-legged  gait  is  produced. 
AVhenever  an  attempt  is  made  at  walking  a  number  of  other  muscle 
groups  are  thrown  into  action.     In  severe  cases  walking  is  impossible. 

Mechanical  treatment  (massage,  extension  of  the  muscles  by  passive 
motion,  and  extension  apparatus),  often  combined  with  division  of  the 
tendons  of  the  muscles  most  involved  with  subsequent  immobilization  in 
plaster-of-Paris  dressings,  is  indicated.  Resection  of  the  motor  nerves 
has  also  been  recommended. 

Paralijiic  contractures  are  most  frequently  the  result  of  anterior 
poliomyelitis,  of  injuries  of  the  peripheral  nerves,  of  neuritis,  and  of 
different  lesions  of  the  brain  and  spinal  cord.  These  contractures  fol- 
lowing flaccid  paralysis  of  a  single  muscle  or  group  of  muscles  are  due 
to  the  contraction,  and  later,  if  not  used,  to  the  shortening  of  the  an- 
tagonistic non-paralyzed  muscle  or  group  of  muscles  (Seeligmiiller's 
antagonistic-mechanical  theory)  or  to  the  weight  of  the  extremity,  which 
is  thrown  upon  the  joints.  Sometimes  the  intact  muscles  hypertrophy. 
Paralytic  talipes  equinus  develops  after  paralysis  of  the  extensor  group 
of  muscles,  and  is  due  to  the  contraction  of  the  muscles  of  the  calf 
and  to  the  weight  of  the  foot.  The  weight  of  the  foot  may,  on  the  other 
hand,  be  sufficient  to  prevent  the  development  of  a  talipes  calcaneus, 
which  may  follow  a  paralysis  of  the  flexor  groups  of  muscles. 

Etiology,  Pathology,  and  Symptoms  of  Anterior  Poliomyelitis. — 
The  etiology  of  infantile  paralysis  (poliomyelitis  anterior)  is  not  ex- 
actly clear.  ["  The  onset  is  usually  sudden,  and  the  paralysis  may  occur 
before  the  development  of  the  general  symptoms.  The  legs  are  more 
frequently  involved  than  the  arms;  the  muscles  are  usually  affected  in 
functionally  similar  groups,  such  as  the  flexors  of  the  forearm,  and 
then  very  rapidly  begin  to  undergo  contractures.  These  produce  de- 
formities, particularly  various  forms  of  club-foot,  scoliosis  or  lordosis, 


706       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND   TUMORS 

and  contractures  of  the  hand." — Musser,  "  Medical  Diagnosis,"  p. 
1038.]  There  are  no  sensory,  bladder,  or  rectal  disturbances;  the  re- 
flexes are  abolished  or  weakened.  The  pathological  changes,  consisting 
of  degeneration  of  the  anterior  hoi-n  cells  with  subsequent  degeneration 
of  the  fibers  arising  from  them  and  the  muscles  supplied  by  them,  are 
most  marked  in  the  cervical  and  lumbar  enlargements  of  the  cord. 

Massage,  electricity  (galvanic),  active  and  passive  motion,  warm 
baths,  and  inunctions  are  indicated  in  the  treatment  of  paralytic  con- 
tractures. Supporting  apparatus  or  immobilizing  dressings  should  be 
applied  to  maintain  the  parts  in  correct  position.  Elastic  bands,  by  the 
contraction  of  which  the  absence  of  muscular  action  is  partially  com- 
pensated, may  be  attached  to  the  mechanical  apparatus. 

,  In  some  cases  tendons  may  be  transplanted  to  advantage.  The  mal- 
formations due  to  shrinkage  and  contraction  of  antagonistic  muscles 
may  be  relieved  by  tenotomy.  If  the  paralysis  is  extensive  a  mechanical 
support  must  be  worn  or  the  joint  opened,  the  articular  surfaces  re- 
moved, and  an  attempt  made  to  secure  a  bony  anchylosis  (arthrodesis) 
in  a  good,  useful  position.  The  results  of  the  latter  operation  are, 
however,  always  doubtful,  as  the  callus  formation  may  be  insufficient 
and  the  union  poor.  Frequently  a  good  position  of  the  parts  may  be 
obtained  by  shortening  the  tendons  involved. 

Arthrogenous  Contractures. — Arthrogenous  contractures  following  in- 
juries and  inflammation  of  joints  are  due  to  shrinkage  and  contraction 
of  the  soft  tissues,  such  as  the  synovial  membrane,  ligaments,  and  peri- 
articular tissues,  entering  into  the  formation  of  the  joint.  In  inflam- 
mations of  joints  the  contractures  are  reflex  and  myogenous  at  first, 
but  later  become  arthrogenous  when  the  capsule  contracts.  Long-con- 
tinued immobilization  after  injuries  favors  the  development  of  con- 
tractures. 

The  stiffness  of  the  joint  or  anchylosis  develops  in  different  waj^s. 
Contraction  of  the  capsule  alone  may  interfere  with  the  movements  of 
the  joint,  as  in  all  forms  of  contractures  connective  tissue  develops  in 
the  joint  which  is  no  longer  used,  uniting  the  articular  cartilages,  and 
if  these  are  destroyed,  the  exposed  surfaces  of  the  bones.  These  fibrous 
adhesions  (anchylosis  fibrosa  intercartilaginea)  later  become  ossified, 
and  b(my  anchylosis  (anchylosis  ossea)  develops.  Bony  anchylosis  may 
develop  without  a  preceding  fibrous  anchylosis,  when  the  articular  car- 
tilages are  destroyed  or  when  callus  forms  within  the  joint  after  frac- 
tur-c.s  involving  the  articular  ends  of  bone. 

The  treatment  of  arthrogenous  contractures  depends  upon  the  degree 
of  anchylosis.  In  fibi-ous  and  capsular  anchylosis  the  deformity  may 
be  corrected  or  improved  by  gradual  extension  Ijy  weight  and  pulley. 
Passive  motion  may  often  be  combined  with  gradual  extension  to  ad- 


DISEASES   OF   JOINTS  707 

vantage.  If  the  lighting  up  of  an  old  inHamniatoi-y  proeess  is  not  to 
be  feared — for  example,  in  traiunatic  anchylosis — the  deformity  may 
be  forcibly  corrected  under  general  anassthesia. 

When  there  is  a  firm  fibrous,  cartilaginous,  or  bony  anchylosis,  re- 
section of  the  joint  is  generally  indicated,  the  object  being  the  for- 
mation of  a  movable  joint  or  one  fixed  in  a  position  which  will  be 
useful. 

In  resection  of  the  knee  and  ankle  joint  an  attempt  should  be  made 
to  obtain  a  bony  anchylosis  in  a  useful  position ;  in  resection  of  the 
shoulder  and  elbow  an  attempt  should  be  made  to  secure  movement  by 
instituting  early  active  and  passive  motion.  [Murphy  has  recently  ob- 
tained some  brilliant  results  in  cases  of  bony  anchylosis  of  the  elbow 
and  knee  by  an  operation  called  arthroplasty,  in  which,  after  resecting 
the  anchylosed  joint,  a  movable  joint  is  obtained  by  placing  between 
the  bones  a  flap  of  connective  tissue  and  fat  from  which  a  new  synovial 
membrane  is  formed,  securing  a  movable  joint.]  If,  as  is  frequently  the 
case  in  pathological  dislocations,  the  adhesions  are  very  extensive,  oste- 
otomy below  the  line  of  the  former  joint  is  generally  to  be  preferred 
to  resection.  If  the  bone  is  cut  through  obliquely  (Konig  and  Hoffa) 
the  deformity  cannot  only  be  corrected,  but  the  shortening  can  also  be 
overcome  by  making  traction  during  the  process  of  repair  by  weight 
and  pulley. 

Tenotoniy,  lengthening,  shortening,  and  transplantation  of  tendons 
are  the  operations  most  frequently  employed  for  the  correction  of  myog- 
enous contractures. 

Technic  of  Tenotomy. — Tenotomy  or  cutting  the  tendons  of  the  short- 
ened muscles  may  be  performed  by  the  subcutaneous  or  open  method. 
In  the  subcutaneous  operation  a  narrow-bladed  knife  or  Dieffenbach's 
sickle-shaped  tenotome  is  used.  [Tenotomy  is  discussed  in  Bryant's 
"  Operative  Surgery,"  Vol.  I,  pp.  329  and  330,  as  follows:  "  Tenotomy 
consists  in  making  a  subcutaneous  or  open  division  of  a  tendon  for  the 
purpose  of  overcoming  or  alleviating  a  deformity  usually  due  to  mus- 
cular contraction.  Since  the  advent  of  antiseptic  surgery,  open  division 
can  be  practiced  with  comparative  uniformity  if  a  rigid  adherence  to 
its  tenets  be  maintained. 

"  However,  it  is  wiser  to  hold  to  the  subcutaneous  method  than  to 
invite  unnecessarily  the  mishaps  that  may  follow  a  faulty  technic  in 
the  open  one.  In  order  to  practice  tenotomy  successfully  the  exact  loca- 
tion of  the  offending  structure  should  be  determined,  together  with  the 
important  contiguous  vessels,  nerves,  etc.  Many  of  the  large  tendons 
are  easily  located  by  their  natural  prominence.  Others  that  ordinar- 
ily lie  concealed  become  apparent  if  coTitraction  and  deformity  have 
occurred,    and    still   more   conspicuous   if   placed   upon   the  stretch   by 


708      SURGICAL  DISEASES,   EXCLUDING  INFECTIONS  AND  TUMORS 


the  surgeon.     The  principles  governing  tenotomy  shouhl  \w  well  con- 
sidered  before   a   tendon   is   divided,   otherwise   an   expedient   of   great 

good  may  become  mischievous  and  even  destructive 

in  its  results. 


Fig.  2G3. 


-Dieffenbach's  Tenotome  and  Subcutaneous  Tenotomy  of  the  Tendo 
achillis. 


"  The  operation  of  tenotomy  is  simplilied  by  attention  to  the  fol- 
lowing order  of  procedure: 

"  1.  Secure  complete  aseptic  technic. 

"  2.  Indicate  on  the  handle  of  the  scalpel  the  direction  of  the  cut- 
ting edge. 

"  3.  Carefully  note  the  length  of  the  blade,  so  as  to  regulate  the 
extent  of  the  division  of  the  tissues. 

"  4.  Avoid,  if  possible,  the  division  of  a  tendon  as  it  passes  through 
a  special  sheath. 

"  5.  Divide  the  tendon  at  a  point  of  greatest  forced  prominence, 
provided  the  division  be  consistent  with  the  safety  of  important  con- 
tiguous structures.  Tf  reflex  spasm  be  provoked  by  '  point  pressure,' 
the  tendon  should  be  divided  at  the  point  exhibiting  the  greatest  reflex 
manifestation   ( Sayre) . 

"  6.  Make  tense  the  structure  to  be  divided,  and  so  pinch  up  or  push 
aside  the  skin  at  the  point  of  proposed  division'  that  when  the  skin  is 
relaxed  the  opening  in  it  will  not  correspond  to  the  divided  tendon. 


DISEASES   OF   JOINTS 


709 


''  7.  Insert  the  blade  on  the  flat  close  to  the  surface  of  the  ten- 
don to  be  divided,  turn  the  edge  toward  the  tendon  and  carefully 
sever  it  with  a  guarded  sawing  motion,  aided  by  pressing  the  tendon 
on  the  cutting  surface  of  the  knife.  If  incautious  force  be  made,  not 
only  the  tendon  but  the  superimposed  tissue  may  be  divided,  thus  com- 
plicating the  treatment  and  recovery. 

"  8.  Carry  the  edge  of  the  blade  away  from  important  structures 
when  possible. 

"  9.  Withdraw  the  blade  while  upon  the  flat.  Follow  the  with- 
drawal with  firm  pressure  upon  the  parts  with  the  thumb  which  should 
finally  rest  on  the  incision.  This  act  will  press  the  blood  and  air  from 
the  wound,  as  well  as  prevent  air  from  entering  it.  Close  the  wound 
with  a  horsehair  stitch  and  seal  it  with  antiseptic  collodion.  The  appli- 
cation and  confinement  to  the  wound  of  an  antiseptic  pad  is  often  quite 
sufficient  for  the  requirements  of  healing. 

"  10.  Rectify  the  deformity  and  confine  the  part  immovably  until 
repair  is  w^ell  advanced."] 

This  operation,  devised  by  Stromeyer.  was  very  popular  in  Dieffen- 
bach's  time.  At  the  present  time  it  is  almost  never  employed  except  for 
division  of  the  tendo  Achillis,  of  the  tendons  about  the  popliteal  space, 
and  the  adductors.  The  last  is  really  a  myo- 
tenotomy, as  the  muscle  fibers  are  also  di- 
vided. 

The  open  method,  in  which  the  tendon  is 
divided  after  having  been  exposed  by  a  free 
dissection,  has  a  number  of  advantages:  (1) 
The  relations  of  the  different  structures  can 
be  seen,  (2)  injuries  of  the  blood  vessels 
may  be  avoided,  (3)  and  shortened  con- 
tracted bands  of  fascia  as  well  as  the  af- 
fected tendon  may  be  divided.  In  cica- 
tricial wryneck  the  contracted  fascia  and 
muscle  are  both  important  factors  in  pro- 
ducing the  deformity. 

Tenotomy  throws  a  muscle  out  of  action 
for  a  short  time  only.     The  blood  clot  form- 
ing between  the  divided  ends  soon  becomes 
infiltrated    with    germinal    tissue    which    is 
later  transformed  into  a  scar,  and  the  con- 
tinuity of  the  tendon  or  muscle  is  then  reestablished.     Tlie  scar  is  com- 
parable to  the  callus  uniting  fragments  of  a  fractured  bone.     Passive 
motion  should  be  begun  at  the  end  of  a  week,  in  order  to  maintain  the 
lengthened  condition  of  the  tendon  or  nuiscle  and  to  prevent  the  recur- 


1 


] 


■A 
Fig.  264. — .\xDKRS()x'si  Doum.E- 
i'H,AP  Method.  A,  Longitudi- 
nal division;  !•$,  flaps  formed; 
C,  tendon  lengthent>d,  flap 
united.  (Bryant's  "Operative 
Surgery.") 


710       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND   TUMORS 


rence  of  shortening  and  contractures,  which  is  frequent  when  proper 
after-treatment  is  not  instituted. 

Tenoplasty,  Indications  and  Technic. — Tendon  lengthening  may  be 
employed  to  correct  the  deformities  resulting  from  the  shortening  of 
tendons  or  muscles.  It  is  practiced  most  frequently  upon  the  larger 
tendons,  such  as  the  tendo  Achillis  and  the  ligamentum  patellge.  A 
tendon  may  be  lengthened,  after  it  has  been  exposed,  by  making  alter- 
nate free  incisions  at  its  borders,  with  subsequent  forcible  extension. 
According  to  Boyer,  the  tendo  Achillis  may  be  lengthened  by  mak- 
ing two  lateral  incisions  in  it  with  the  tenotome,  one  incision  being 
just  above  the  heel,  the  other  somewhat  higher  on  the  other  side  of 
the  tendon.  [Bryant  says  that  the  making  of  al- 
ternate free  incisions  at  the  borders  of  a  tendon — 
the  accordion  plan — so  as  to  cause  the  tendon  to 
assume  an  accordionlike  appearance  when  length- 
ened is  much  more  ingenious  than 
practical 


Fig.  2G5. — A.  Poncet's 
AfcoRDioN  Method. 
(Hryant'.s  "Operative 
Surgery.") 


Fig.  266.  Fig.  267. 

Fig.  2G6. — Incision  Method.     (Bry-  Fig.     268. — Lengthen- 

ant's  "Operative  Surgery.")  ing  Tendo  Achillis. 

Fig.  267. — Tendon   Lengthened  in  (Bryant's  "Operative 

Incision  Method.    (Bryant's "Op-  Surgery.") 
erative  Surgery.") 


Tendons  may  be  lengthened  and  their  continuity  still  be  preserved 
by  making  a  Z-shaped  incision  into  the  tendon  and  then  making  ex- 
tension.    When  the  tendon  is  extended  the  ends  of  the  Z  can  be  dis- 


DISEASES   OF   JOINTS  711 

placed  and  sutured  together.  Tendon  lengthening  is  used  in  place 
of  tenotomy  when  the  shortening  is  extreme,  and  in  the  treatment  of 
contractures  involving  the  tendons  of  the  muscles  of  the  fingers  where 
subsequent  failure  of  union  of  the  divided  ends  is  feared. 

Tendon  sliortening   is  employed  for  the   purpose  of  improving  the 
action  of  muscles  where  power  is  lessened  as  the  result  of  a  complete 
or  incomplete  paralysis,  and  for  the  pur- 
pose of  maintaining  the  joints  in  a  correct  /^ 

or  iLseful  position.      [Bryant  shortly  sum-      *" 
marizes   the   general   principles   of   tendon 
shortening   as   follows:    "The   removal   of 
a  proper  segment  of  a  tendon  and  union 
of  the  divided  extremities   can  be  accom- 
plished by  either  a  simple  obliciue  incision  ^ 
^                   /               .   .                          ...            Fig.  2G9. — rLicATioN  of  a  Ten- 
or  laterjd  apposition  and  union  or  by  the               don.    (After  Lange.) 

introduction  of  the  wedge-formed  extrem- 
ity of  one  into  the  split  end  of  the  other  and  fixation  with  sutures."] 
Tendons  may  also  be  shortened  without  division  by  plication  or  folding 
upon  a  heavy  silk  suture.  In  paralytic  fiail  joints,  shortening  of  a  num- 
ber of  the  tendons  of  the  muscles  surrounding  the  joint  (tendinous 
fixation)  may  be  done  to  advantage. 

Transplantation  of  Tendons. — The  displacement  or  transplantation 
of  tendons  may  be  performed  for  the  correction  of  paralytic  con- 
tractures. This  method,  the  description  of  which  has  already  been 
given  in  discussing  the  repair  of  traumatic  tendon  defects,  may 
be  combined  in  a  number  of  different  ways  with  tendon  lengthen- 
ing and  shortening.  The  following  are  simple  examples  of  this  most 
useful  procedure:  In  paralytic  club-foot  the  pai-alyzed  peronei  mus- 
cles may  be  divided  and  their  distal  ends  united  with  a  flap  from 
the  functionating  tendo  Achillis  {vide  p.  536)  ;  in  paralytic  fiat-foot 
the  tendon  of  the  paralyzed  tibialis  anticus  may  be  divided  and  its 
distal  end  united  with  the  non-paralyzed  extensor  hallucis  longus; 
in  paralysis  of  the  (juadriceps  extensor,  F.  Krause  has  separated  the 
tendons  of  the  flexors  at  their  attachment  and  sutured  them  to  the 
patella ;  in  the  case  of  paralysis  of  the  musculospiral  nerve  Iloft'a  nsed 
a  similar  method,  separating  the  flexor  carpi  radialis  and  ulnaris  at 
their  insertions  and  suturing  them  into  the  distal  parts  of  the  ex- 
tensors. 

In  all  cases  the  tendons  must  be  united  under  such  tension  that  the 
deformity  will  be  overcorrected.  If  repair  occurs,  after  immobilization 
in  the  overcorrected  position  for  six  or  eight  weeks,  the  results  are 
usually  very  good,  as  the  displaced  or  transplanted  muscle  or  tendons 
assume  the  function  of  the  paralyzed  ones. 


712       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND   TUMORS 

Literature. — Bardenheuer.  Ischamische  Kontruktur.  Festschrift  zur  ICioffiiiing 
der  Akacleinie.  Koln,  1904,  p.  34. — ■Bayer.  Eine  Vereinfachung  der  plawtichen  Achil- 
\otomie.  Zentralblatt  fiir  Chirurgie,  1901,  p.  37. — Drobnik.  Ueber  die  Behandlung 
der  Kinderlahniung  init  Funktionsteilung  und  Funktionsubertragung  der  Muskeln. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  43,  1896,  p.  473. — Gerlach.  Klinisch-statistischer 
Beitrag  zur  Frage  der  Sehnenplastik  und  Sehnentransplantation.  I.-D.  Rostock, 
1904. — Hoffa.  Die  Orthopadie  im  Dienste  der  Nervenheilkunde.  Jena,  1900; — 
Lehrbuch  der  orthopadischen  Chirurgie.  Stuttgart,  1906;— Ueber  Enderfolge  der 
Sehnenplastik.  Chir.  Kongr.-Verhandl.  Berlin,  1904,  I,  24. — Fedor  Krause.  Ersatz 
des  gelahniten  Quadriceps  femoris  durch  die  Flexoren  des  Unterschenkels.  Deutsche 
uietl.  Wochenschr.,  1902,  p.  118. — Nicoladoni.  Nachtrag  zum  Pes  calcaneus  und  zur 
Transplantation  der  Peronealsehne.  Arch.  f.  klin.  Chir.,  Bd.  27,  1882,  p.  600. — Oppen- 
heim.  Lehrbuch  der  Nervenkrankheiten.  Berlin. — Rosenkranz.  Ueber  kongenitale 
Kontrakturen  der  oberen  Extremitaten.  Zeitschr.  f.  orthop.  Chir.,  Bd.  14,  1905,  p.  52. 
— ■Vulpius.  Ueber  die  Heilung  von  Lahmungen  und  Lahmungsdeformitaten  mittels 
Sehneniiberpflanzung.     v.  Volkmanns  Samml.  khn.  Vortr.     N.  F.,  No.  197,  1897. 


(c)  SPECIAL  DISEASES  OF  THE  JOINTS 
(1)    CHRONIC   SEROUS  SYNOVITIS 

Nature  of  Chronic  Synovitis. — The  symptoms  of  chronic  irritation 
of  the  synovial  membrane  which  leads  to  the  formation  of  a  serous 
exudate,  thickening  of  the  joint  capsule,  and  hypertrophy  of  the  syno- 
vial villi  are  similar  to  those  of  acute  serous  synovitis,  with  this  dif- 
ference, that  there  is  little  or  no  inflammatory  reaction.  Chronic  syno- 
vitis is  much  more  frequently  the  result  or  symptom  of  some  other 
disease  of  the  joint  than  an  independent  clinical  entity.  It  follows 
rheumatism,  ha-marthrosis,  floating-  bodies,  and  arthritis  deformans, 
or  develops  in  a  previously  healthy  joint  as  the  first  symptom  of  some 
specific  disease,  such  as  tuberculosis,  syphilis,  arthritis  deformans,  or 
neuropathic  arthritis. 

Usually,  chronic  serous  synovitis  develops  in  but  one  joint.  The 
knee  is  afil'ected  most  commonly,  but  it  also  occurs  frequently  in  the 
elbow,  ankle,  and  wrist  joints.  Involvement  of  many  joints  is  rare 
and  suggests  some  general  cause,  such  as  chronic  articular  rheumatism, 
articular  syphilis,  etc.  The  changes  in  the  form  of  the  joints  are  rather 
characteristic  as  the  capsule  is  distended  and  prominent  at  all  yielding 
|)()ints  and  tlu>  normal  contour  of  the  joint  with  its  prominences  and 
depressions  is  obliterated.  Chronic  serous  synovitis  develops  slowly  and 
may  reiii.iiii  stationary  for  a  long  time.  Exacerbations  following  use 
of  tlie  joint  are  frecjuent,  but  sometimes  the  synovitis  subsides  spon- 
taneously when  care  is  exercised.  If  the  synovial  fringes  become  hyper- 
tropliied  jind  inflammatory  masses  I'oi-m  in  the  capsule,  a  condition 
reseiiihliii'^'-  osleo.-irtliritis  develops.  Tbe  sharp'  contour  of  the  tense 
ca|)snle    I  hen    bceomrs   lost  and   the   palpable   thickenings   and   nodules 


DISEASES   OF   JOINTS  713 

in  the  inflaniiMl  capsule  gradually  become  fused  with  the  suiToumling 
tissues. 

Symptoms. — The  symptoms  in  the  beginning  are  insignificant.  Un- 
less the  synovitis  follows  a  ha'marthrosis  or  some  acute  painful  inflam- 
mation, the  patient  is  often  unable  to  state  exactly  when  the  trouble 
began.  A  sense  of  fullness  in  the  joint,  of  uselessness  and  weakness  of 
the  extremity  is  frequently  the  only  complaint.  Later  in  neglected 
eases  when  the  ligaments  have  become  relaxed  malformations  (such  as 
genu  valgum,  g.  varum,  g.  recurvatum,  and  subluxations)  develop. 
Painful  anchylosis  develops  if  the  capsule  becomes  thickened  and  the 
villi  hypertrophied. 

Diagnosis. — The  diagnosis  of  chronic  serous  synovitis  is  not  dif- 
ficult. The  chronic,  almost  painless,  course,  the  changes  in  the  form 
of  the  joint,  the  signs  of  fluid  elicited  by  palpation  and  patellar  balotte- 
ment  are  characteristic.  Hypertrophied  synovial  fringes  and  inflam- 
matory masses  in  the  capsule  are  most  easily  palpated  after  the  exudate 
has  been  partially  removed.  Then,  when  the  joint  is  moved,  a  crepitus 
and  rubbing  can  be  felt  and  heard. 

It  is  frequently  difficult  to  determine  the  cause  of  the  synovitis 
when  it  is  the  first  symptom  and  not  the  result  of  some  previous  disease 
of  the  joint.  In  these  cases  further  observation  is  necessary  before  an 
exact  diagnosis  can  be  made. 

Treatment. — If  the  exudate  is  small  in  amount,  rest,  elastic  com- 
pression, massage,  and  passive  motion  are  indicated.  If  the  symptoms 
do  not  subside  after  this  treatment,  or  if  the  effusion  is  great,  the  latter 
should  be  removed  by  aseptic  puncture,  with  subsequent  washing  out 
of  the  joint  with  a  three  per  cent  solution  of  carbolic  acid.  After 
aspiration  and  injection  the  joint  should  be  immobilized  for  a  few  days. 
Absorption  of  an  exudate  is  favored  by  massage  and  hot-air  treatment; 
active  and  passive  motion  prevent  the  formation  of  adhesions.  Painful 
thickenings  of  the  synovial  membrane  may  require  removal. 

(2)  CHRONIC    ARTICULAR    RHEUMATISM 

Nature  and  Pathology, — By  chronic  articular  rheunuitism  is  under- 
stood a  chronic,  painful  inflammation  of  the  synovial  membrane,  cap- 
sular ligament,  and  periarticular  tissues.  Hypertrophy  of  the  synovial 
membrane  causes  a  swelling  of  the  joint,  contraction  of  the  tissues  of 
the  capsule,  limitation  of  motion. 

Frequently  the  articiUar  cartilages  become  fibrillated  and  destroyed, 

and  replaced  by  a  vascular  connective  tissue.     In  this  Avay  the  joint 

cavity  is  gradually  obliterated ;   anchylosis  and  contractures,  to  which 

atrophy  of  the  muscles  surrounding  the  joint  and  contraction  of  the 

capsule  contribute,  develop.     The  dry  form  (arthritis  sicca)   of  chronic 
40 


714       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND   TUMORS 

articular  rheiuiiatisin  is  more  coninion  than  the  form  associated  willi 
a  serous  exudate  and  ending  in  hydrarthrosis.  ["  Chronic  articuhir 
rheumatism  never  leads  to  sujopuration  and  never  to  true  caries,  the 
pathological  changes  presenting  more  of  a  similarity  to  arthritis  de- 
formans, except  that  in  the  latter  disease  there  is  more  of  an  increased 
growth  of  cartilage,  while  in  the  former  the  cartilage  is  replaced  by 
vascular  connective  tissue.  But  deformities  of  the  joints,  subluxations 
and  luxations  develop  in  chronic  articular  rheumatism  as  they  do  in 
arthritis  deformans." — Tillmanns'  "  Text-book  of  Surgery,"  Vol.  I, 
p.  670.] 

The  nature  of  articular  rheumatism  is  obscure.  There  are  a  num- 
ber of  transitional  forms  between  chronic  serous  synovitis  and  chronic 
articular  rheumatism,  and  between  the  latter  and  arthritis  deformans. 
It  is  frequently  mistaken  for  gout,  arthritis  deformans,  gonorrheal 
arthritis,  even  for  tuberculosis.  It  should  also  be  remembered  that  a 
nundDer  of  lesions  which  dififer  clinically  and  etiologically  are  grouped 
under  the  term  chronic  articular  rheumatism,  as  characteristics  which 
make  a  differential  diagnosis  possible  are  wanting. 

Etiology. — Nothing  definite  is  known  concerning  the  etiology  of  this 
disease.  It  is  questionable  whether  the  short  bacillus  demonstrated  by 
Schiiller  is  to  be  accepted,  and  yet  it  cannot  be  doubted  that  at  least 
some  of  the  cases  are  due  to  bacterial  infections.  The  not  infrequent 
development  of  chronic  articular  rheumatism  from  the  acute  form,  the 
simihirity  of  the  former  to  the  arthritis  of  gonorrheal  origin,  the  acute 
and  subacute  exacerbations,  which  are  frequent  during  the  chronic 
course  of  the  disease,  all  indicate  a  bacterial  origin.  Clinical  experi- 
ence^ lias  demonstrated  that  getting  wet,  exposure  to  cold,  and  residence 
in  (laiiii),  cold  dwellings  or  regions  favor  the  development  of  the  disease. 

The  disease  is  observed  almost  exclusively  in  adults,  the  female  being 
more  freriucntly  attacked  than  the  male.  Chlorosis  seems  to  be  an  etio- 
logical factor  ill  young  girls,  arteriosclerosis  in  old  people. 

Usually  a  number  of  difli'erent  joints  are  involved,  rarely  a  single 
one.  In  severe  cases  all  the  joints  may  be  attacked.  The  disease  is 
most  comiiion  in  the  knee  and  shoulder  joints  and  in  the  joints  of  the 
fingers  and  toes. 

Symptoms  and  Course. — The  onset  is  at  times  slow  and  insidious;  at 
other  times  the  disease  develops  as  a  sequela  to  acute  articular  rheu- 
matism. Schiiller  lias  differentiated  three  forms — the  simple,  severe, 
and  (iiKln/losing — depending  upon  the  clinical  course  of  the  disease  and 
tlir  pathological  changes  in  the  joints.  In  the  simple  form  the  pain  in 
11i«'  joints,  which  gradually  become  swollen  as  the  capsule  thickens,  is 
slight.  It  is  increased  by  movements  and  pressure,  is  most  marked  in 
the  morning  after  the  night's  rest,  and  when  the  patient  attempts  to 


DISEASES   OF   JOINTS 


715 


OF     THE 

(Woman 


walk  after  sitting  for  a  number  of  hours.  The  pains  come  and  go. 
Exacerbations,  accompanied  by  an  effusion  into  the  joint  rendering 
motions  more  difficult,  become  frequent,  while  the  swelling  of  the  joints 
increases  and  becomes  more  distinct  as  the  muscular  atrophy  increases 
and  the  stiff  joints  assume  abnormal 
positi(ms.  The  deformities  are  most 
juarked  in  the  hands.  The  meta- 
carpo-phalangeal  joints  become  very 
prominent  upon  the  dorsum  of  the 
emaciated  hand,  the  proximal  pha- 
langes become  extended,  while  the 
remaining  ones  become  flexed  and 
the  hand  (on  account  of  its  weight) 
becomes  displaced  to  the  ulnar  side 
(Fig.  270).  Subluxations  of  the 
proximal  and  lateral  displacements 
of  the  distal  phalanges  in  extension 
are  frequent.  In  the  larger  joints, 
where  the  capsule  is  accessible,  the 
hypertrophied  synovial  fringes  may 
be  palpated  as  small  nodules.  Dur- 
ing movements  these  masses  rubbing 
upon  each  other  produce  a  peculiar 

creaking  and  rubbing  sensation.    The  symptoms  and  pathological  changes 
remain  stationary  or  pass  into  those  of  the  severe  form. 

In  the  severe  form  the  hypertrophy  of  the  synovial  villi  is  marked. 
In  the  course  of  time  the  entire  surface  of  the  synovial  membrane  be- 
comes covered  with  simple,  club-shaped  or  branched  villuslike  growths 
which  are  very  vascular  and  develop  from  the  normal  synovial  fringes. 
As  these  develop  they  fill  the  entire  joint  cavity  and  distend  the  cap- 
sule. The  sharp,  severe  pains  are  increased  by  acute  inflanmiatory 
exacerbations,  accompanied  by  oedema  and  some  redness  of  the  skin 
and  a  slight  elevation  of  temperature.  Movements  become  more  and 
more  painful  and  limited  as  the  thickened  capsule  contracts,  as  it  gradu- 
ally fuses  with  the  surrounding  tissues,  and  as  the  margins  of  the 
articular  cartilages  become  fibrillated  and  transformed  into  fibrous  tis- 
sue. The  joints  become  considerably  swollen.  The  boundaries  of  the 
swelling,  which  become  more  pronounced  as  the  muscles  atrophy  and  the 
contractures  develop,  are  not  sharply  defined.  The  swelling  often  is 
comparable  to  that  which  occurs  in  tuberculous  arthi-itis  (von  Volk- 
mann).  Hard  nodules  in  the  capsule  and  the  hyperti-ophied  villi  may 
be  palpated  through  the  soft  tissues.  When  passive  movements  are  made 
a  grating  may  be  felt  and  heard.    If  almost  all  the  joints  are  involved 


Fig.    270. — Chronic    Arthritis 
Joints    of    the    Fingers. 
fifty-five  j'ears  of  age.) 


716       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 

the  patient  lies  helpless  in  bed,  dying  after  a  number  of  years  of 
exhaustion. 

The  third  form  (arthritis  chronica  rheumatica  ankylo-poetica)  is  the 
most  advanced.  It  may  be  preceded  by  one  of  the  forms  above  described 
or  develop  independently.  The  hypertropliied  and  thickened  capsule 
shrinks  and  contracts,  while  the  articular  cartilages  become  fibrillated 
and  destroyed  by  the  pressure  of  the  newly  formed,  vascular  masses  of 
connective  tissue.  The  articular  surfaces  are  denuded  and  become  ad- 
herent. Bony  anchylosis  may  develop  from  this  fibrous  anchylosis, 
which  is  accompanied  by  subluxations  and  contractures. 

Striimpell  and  P.  Marie  have  described  a  progressive  anchylosis  of 
the  spinal  column  (chronic  anchy losing  spondylitis)  proceeding  from 
below  upward  which  is  associated  with  anchylosis  of  some  of  the  larger 
joints.  Bechterew  has  also  observed  cases  of  anchylosis  of  the  spine 
accompanied  by  pain  and  symptoms  due  to  compression  of  the  roots 
of  spinal  nerves  (neuralgias,  flaccid  paralyses  of  the  muscles  of  the 
extremities).  The  form  of  anchylosing  spondylitis  described  by  Bech- 
terew differs,  however,  in  a  good  many  respects  from  that  described 
by  Striimpell  and  Marie. 

The  anatomical  investigations  of  E.  Friinkel  have  shown  that  both 
these  forms  of  spondylitis  have  about  the  same  pathological  basis, 
namely,  an  inflammation  of  the  small  vertebral  joints  leading  to  an  an- 
chylosis. The  periosteal  growths  are  secondary  and  are  due  to  altered 
static  conditions.  Both  of  these  forms,  therefore,  belong  to  chronic 
articular  rheumatism  and  not  to  arthritis  deformans. 

Prognosis. — The  cure  of  chronic  articular  rheumatism  is  not  to  be 
expected.  Even  the  mildest  forms  may  continue  through  life.  The 
severest  forms  may,  however,  be  somewhat  alleviated  except  when  all 
tlic  joints  are  involved  and  anchy losed. 

Diagnosis. — It  is  often  impossible  to  make  an  absolute  diagnosis  be- 
tween chronic  articular  rheumatism,  chronic  gonorrheal  arthritis,  gout, 
and  arthritis  deformans.  Often  tuberculous  arthritis  cannot  be  posi- 
tively excluded. 

Treatment. — The  greater  part  of  the  treatment  of  chronic  articular 
rheumatism  belongs  to  internal  medicine.  Salicylates,  hydrotherapy 
(steai-u  and  Turkish  baths,  hot  compresses),  massage,  and  gynmastic 
exercises  have  been  employed.  A  prolonged  stay  at  hot  springs,  such  as 
Te[)li1/,  AVildbad,  (iastein,  Wiesbaden,  Baden-Baden,  Hot  Springs  (Ar- 
kaiis;isj,  While  Siilpluir  Springs  (Virginia),  and  change  of  residence  to 
a  warm,  diw  cliniate,  are  often  of  value. 

liier's  pjissive  hypera-niia  lessens  the  pain  and  favors  the  separaticm 
•  •r  liltroMs  adh(«ions.  It  may  be  alternated  with  treatment  by  the  hot-air 
iip|.;iratus  {vide  p.  310).    The  edematous  infiltration  of  the  tissues  and 


DISEASES  OF  JOINTS  717 

the  improvement  of  the  eirenlatioii  (U^hiy  the  cicatricial  contraction  of 
the  tissues  and  ren(U>r  the  joint  more  movable.  According:  to  Biidinger, 
the  injection  of  sterilized  vaselin  (1-4  c.c.)  into  the  aft'ected  joint  is 
of  value. 

The  contractures  may  be  corrected  by  gradual  reduction  by  weight 
and  pulley,  or  by  forcible  reduction  luider  general  anaesthesia.  If  the 
joints  are  painful  an  attempt  should  be  made  to  secure  anchylosis  in 
a  useful  position  by  immobilizing  the  part  in  a  plaster  cast;  otherwise, 
an  attempt  should  be  made  to  prevent  anchylosis.  Kesection  should  be 
considered  when  contractures  in  poor  positions  develop.  Large  capsular 
gro^Hhs  and  hypertrophied  synovial  fringes  should  be  removed. 

(3)    ARTHRITIS  DEFORMANS —OSTEO-ARTHRITIS  CHRONICA  DEFORMANS 

Nature  and  Pathology  of  Arthritis  Deformans. — The  i)athological 
processes  occurring  in  arthritis  deformans  differ  from  those  of  chronic 
articular  rheumatism,  but  the  clinical  pictures  at  the  beginning  are 
often  very  similar.  In  arthritis  deformans  the  changes  in  the  cartilages 
and  bones  (atrophy  and  proliferation  alternating)  are  the  most  promi- 
nent, but  the  capsule  and  synovial  villi  also  become  hypertrophied  and 
thickened  as  in  chronic  articular  rheumatism.  Arthritis  deformans  also 
differs  from  chronic  articular  rheumatism  in  the  absence  of  adhesions 
between  the  articular  surfaces. 

In  arthritis  deformans  the  articular  cartilages  become  softened,  fibril- 
lated,  and  fissured  at  the  points  where  they  are  exposed  to  the  greatest 
pressure.  The  bone  is  then  exposed  and  becomes  smooth  and  polished 
off'  by  the  movements  of  the  joint.  Nodular  masses  of  cartilage  (ecchon- 
droses),  which  later  become  transformed  into  osteoid  tissue  and  true 
bone,  develop  at  the  margins  of  the  joint.  These  cartilaginous  masses 
are  at  first  united  by  a  pedicle,  but  as  they  enlarge  the  pedicle  becomes 
thinner,  until  finally  it  is  destroyed  and  the  cartilaginous  masses  become 
free.  Floating  cartilages  may  develop  in  this  way.  The  bone  disap- 
pears spontaneously  by  absor]ition,  while  the  bone-marrow  assumes,  as 
the  fat  is  absorbed,  a  gelatinous,  or  as  liquefaction  occurs,  a  cystic, 
appearance  (Ziegler).  The  spongy  bone  lying  beneath  the  articular 
cartilage  becomes  softened  and  yielding,  and  gradually  flattens  where 
exposed  to  pressure.  At  the  same  time  bone  develops  from  the  perios- 
teum adjacent  to  the  articular  cartilage,  which  unites  with  the  masses 
developing  from  the  margins  of  the  cartilage  to  form  large,  nodular 
marginal  growths.  [A  characteristic  "  lipping  "  of  the  margin  of  the 
cartilage  develops  in  this  way.]  Capsular  changes  are  associated  with 
these  cartilaginous  and  bony  changes.  The  capsule  becomes  thickened 
and  shrunken.  At  times  plates  and  spiculae  of  bone  develop  within  it, 
while  the  surface  of  the  synovial  membrane  may  be  covered  with  pro- 


718       SURGICAL   DISEASES,    EXCLUDING   INFECTIONS  AND  TUMORS 

liferating,  hypertrophied  villi.  The  latter  may  be  partly  fibrous,  i)artly 
fatty;  often  they  contain  cartilaginous  foci.  Floating  cartilages  are 
often  formed  by  the  detachment  of  thickened  calcified  villi. 

The  entire  joint  becomes  greatly  changed  by  these  processes.  The 
articular  ends  of  the  bones  become  flattened,  broad,  and  surrounded  by 
an  irregular  row  of  osteophytes;  the  articular  surfaces  become  widened, 
their  margins  thickened  and  irregular.  Depressions  and  cavities  alter- 
nate with  grooved  and  smooth  surfaces.  The  deformed  ends  of  the 
bones  entering  into  the  formation  of  the  diseased  joint  are  surrounded 
by  nodular  masses  of  bone  or  cartilage  and  knoblike  tuberosities.  Be- 
tween these  masses,  in  the  depressions  and  grooves,  are  often  found  in- 
numerable, larger  or  smaller,  free  or  pedunculated,  bodies. 

,  It  may  be  years  before  the  changes  become  as  marked  as  described 
above.  The  disease  is  characterized  by  a  slow  but  steadily  progressive 
course,  and  although  it  may  remain  stationary  for  a  time,  a  subsidence 
is  extremely  rare  and  has  been  observed  only  at  the  beginning  of  the 
disease. 

Joints  Most  Frequently  Involved. — Arthritis  deformans  is  most  com- 
monly observed  in  the  hip  and  knee  joints,  and  then  in  order  of  fre- 
quency in  the  elbow,  Avrist,  shoulder,  and  ankle  joints,  in  the  spinal  col- 
umn and  interphalangeal  joints.  The  disease  may  develop  in  a  single 
joint  (especially  the  large  ones)  or  simultaneously  in  a  number  of  joints. 
It  is  more  frequent  in  the  male  sex.  It  begins,  as  a  rule,  in  middle  life, 
but  may  develop  in  children  and  young  adults. 

Nothing  definite  is  known  concerning  the  cause  of  arthritis  de- 
formans. We  only  know  that  injuries  to  the  joints  and  the  factors 
already  mentioned  in  chronic  articular  rheumatism  play  a  role. 

Malum  Senile. — Tliis  is  a  chronic  disease  of  the  joints  occurring  in  old 
people  and  attacking  most  fre(iuently  the  hip  joint,  but  also  the  shoul- 
der and  el])()w  joints.  It  differs  from  arthritis  deformans  in  the  absence 
of  bony  and  cai'tilaginous  growths.  The  atrophy  and  destruction  of 
the  ends  of  the  bones  are  j)robably  due  to  senile  nutritional  disturbances, 
and  res('iii))le  the  |)rocesses  occurring  in  arthritis  chronica  ulcerosa  sicca 
(Ziegler).  The  capsule,  however,  becomes  thickened  and  the  synovial 
villi  hypertro])hied.  Similar  changes  occur  in  patients  of  advanced  age 
whose  extremities  have  been  inunobilized  in  dressings  for  a  long  time 
and  have  not  bcm  used. 

Symptoms. — Artln-itis  deformans  has  an  insidious  onset.  For  a  long 
liiiK;  slight  pain,  creaking  and  rubbing  of  the  joint  on  movement,  and 
a  sense  of  stiffness  most  maj-ked  after  keeping  the  joint  at  rest  for  a 
long  time,  and  disappearing  rapidly  when  the  limb  is  used  mfiy  be  the 
only  symy)toms.  Fi'om  tiine  to  time  a  serous  exucfate  is  jxmred  out  into 
llie  jdint.     The  efi'usion  recurs  frequently  when  there  are  free  bodies 


DISEASES  OF   JOINTS  719 

in  the  joint  which  irritate  the  synovial  membrane.  It  is  frequently  the 
first  thing  to  direct  the  attention  of  the  patient  to  the  disease.  (jJradu- 
ally  the  form  of  the  joint  changes.  The  joint  swells  as  a  result  of 
the  thickening  of  the  capsule  and  enlargement  of  the  bones,  irregular 
prominences  forming  about  it. 

The  greater  the  alteration  in  the  shape  of  the  joint,  the  gi-eater  the 
limitation  of  motion  due  to  the  development  of  marginal  osteophytes 
which  interfere  with  the  normal  movements  of  the  l)ones,  the  more 
marked  the  deformities,  such  as  genu  valgum,  varum,  etc.,  are.  Move- 
ments are  often  very  painful  when  the  bony  changes  are  becoming  ad- 
vanced. The  joint,  in  spite  of  the  contraction  of  the  capsule,  which  may 
lead  to  a  capsular  anchylosis,  becomes  weak  and  flail,  and  finally  patho- 
logical dislocations  and  contractures  develop. 

In  spite  of  the  number  of  disturbances  and  the  steady,  progressive 
nature  of  the  disease,  there  are  no  inmiediate  dangers  to  life. 

Diagnosis. — The  diagnosis  is  based  upon  the  thickening  of  the  cap- 
sule, the  serous  effusion,  the  creaking  and  rubbing  elicited  by  move- 
ments of  the  joint,  the  palpable  marginal  osteophytes  and  knoblike 
tuberosities,  and  upon  the  presence  of  free  bodies  in  the  joint  cavity. 
In  the  beginning,  arthritis  deformans  is  very  similar  to  chronic  articular 
rheumatism,  especially  if  a  number  of  different  joints  are  involved. 
Neuropathic  joint  lesions  are  usually  painless,  and  a  careful  exami- 
nation will  reveal  the  principal  disease.  Joints  attacked  by  arthritis 
deformans,  which  are  fixed  or  but  slightly  movable,  may  be  easily  mis- 
taken for  tuberculous  joints. 

Treatment. — The  same  methods  and  drugs  are  used  in  the  treatment 
of  arthritis  deformans  and  of  chronic  articular  rheumatism.  Contrac- 
tures due  to  capsular  changes,  which  are  infrequent,  may  be  forcibly 
corrected;  if  necessary,  under  general  anai^sthesia.  If  the  pathological 
changes  in  one  of  the  larger  joints  are  advanced  and  the  deformity  is 
marked,  resection  of  the  joint  may  be  performed.  In  resection  of  the 
joints  of  the  upper  extremity  and  of  the  hip  an  attempt  should  be  made 
to  secure  a  good  range  of  motion,  while  after  resection  of  the  knee 
and  ankle  joints,  bony  anchylosis  in  a  useful  position  is  desired.  Occa- 
sionally amputation  is  indicated  in  old  people,  when  the  destruction  of 
the  knee  or  ankle  joint  is  advanced. 

Free  Joint  Bodies,  Floating-  Cartilages. — Loose  bodies  in  a  joint  give 
rise  to  special  symptoms.  These  free  bodies  are  due  to  the  separation  or 
breaking  off  of  fibrous  (later  calcified),  or  cartilaginous  synovial  fringes, 
or  of  ecchondroses.  Sometimes  they  lie  in  the  grooves  and  depressions  in 
the  joints,  at  other  times  they  glide  rapidly  hither  and  thither  when  move- 
ments are  made.  They  are  often  connected  with  the  articular  surfaces  or 
to  the  synovial  membratu^  by  a  delicate  fibrous  ])edicle.     Free  bodies  are 


720       SURGICAL   DISEASES,   EXCLUDING    INFECTIONS   AND  TUMORS 


Fig.  271. — Free  Bodies  Removed  from  a  Knee  in  a 
Case  of  Arthritis  Deformans.  (Male  patient 
thirty  years  of  age.) 


frequently  found  in  arthritis  deformans,  and  if  the  pathological  changes 
are  limited  in  extent  the  symptoms  caused  by  them  may  be  the  most 
prominent  feature.  Free  bodies  may  even  be  found  in  joints  in  which 
no  trace  of  arthritis  deformans  can  be  discovered,  and  where  no  history 
of  previous  injury  to  the  joint  can  be  elicited.     Konig  believes  that 

in  these  cases  larger  or 
smaller  pieces  become  sep- 
arated from  the  articular 
ends  of  the  bones,  much  as 
a  sequestrum  is  separated, 
by  some  process  the  nature 
of  which  is  obscure.  He 
has  given  the  name  of  os- 
tcochondritis  diseccans  to 
this  obscure,  circumscribed 
disease  of  the  ends  of  the 
bones.  The  loss  of  sub- 
stance in  the  bone  is  re- 
paired by  the  proliferation  of  the  surrounding  cartilage.  It  is  still 
possible  that  even  in  these  cases  a  slight  trauma  preceded  the  formation 
of  the  free  bodies. 

The  pathological  or  arthritic  free  bodies  differ  from  the  traumatic 
ill  aj^pearance.  The  former  have  a  mulberry  appearance,  which  is  due 
to  the  proliferation  of  the  cartilage  surrounding  the  bony  nucleus,  while 
the  latter  are  smootli.  They  contain  hyaline  and  fibrous  cartilage,  cal- 
cified fibrous  tissue  and  bone.  Bone  frequently  forms  the  nucleus  of  the 
free  bodies.  If  the  structure  indicates  that  the  body  was  derived  from  a 
normal  Mrticular  surface,  it  is  probably  of  traumatic  origin.  They  may 
occur  singly  or  in  lai'ge  numbers,  and  vary  in  size  from  a  pea  to  a 
walnut. 

S!jni]>l()}iis. — The  ])riucipal  symptom  caused  by  free  bodies  in  the 
joint  is  sudden,  severe,  often  agcmizing,  pain  expei'ieiiced  when  some 
]);ii-ticu]nr  movement  is  made.  The  joint  then  becomes  locked  and  the 
]);iticnt  falls  to  the  ground  as  a  result  of  the  interference  with  the  func- 
tion of  the  joint,  oi'  faints  because  of  the  severe  pain.  These  symptoms, 
wliich  ai-c  not  infre(|U('ntly  followed  by  a  serous  synovitis,  are  due  to 
tlic  i Ilea rccral ion  of  the  free  body  between  the  articular  surfaces. 

Join  Is  ill  which  Free  Bodies  Oeeur  Most  Commonly  and  Diagnosis. 
— Free  bodies  are  foinid  most  frecjucntly  in  the  knee,  elbow,  and  hip 
joints,  especially  in  poweffnl  men  ol'  middle  age.  The  diagnosis  is  not 
(liffieuH  when  the  symptoms  ai'c  ])ronoinu'('d,  and  a  history  of  a  number 
III'  |»revious  attacks  of  locking  of  tlie  joint  can  be  (>licited.  If  the  free 
l'"dies   are    in    an   inaccessible   part  of   the  joint   and   cannot   therefore 


DISEASES   OF   JOINTS 


721 


be  palpated,  they  may  be  demonstrated  in  X-ray  pictures  unless  they 
consist  merely  of  fibrous  tissue  or  cartilage.  [It  should  be  remembered 
in  interpreting  X-ray  pictures  of  the  knee  joint,  that  there  is  frequently 
a  sesamoid  bone  in  the  internal  head  of  the  gastrocnemius  which  casts  a 
shadow.  The  shadow  cast  by  this  sesamoid  bone  should  not  be  inter- 
preted as  due  to  a  free  body.] 

Indications  for  Tnatnicnt. — If  the  free  bodies  cause  symptoms  they 
should  be  removed.  As  a  rule,  these  bodies  can  be  removed  through  a 
small  incision  in  the  capsule. 
When  they  can  be  palpated, 
cocain  anaesthesia  is  sufficient. 
Of  course  these  operations 
should  be  performed  under  ar- 
tificial ischaiuia  and  under  the 
greatest  possible  precautions  to 
secure  asepsis.  If  there  are  a 
number  of  free  bodies  a  large 
incision  may  be  required.  If 
during  the  operation  the  free 
body  becomes  lost  in  the  joint 
cavity,  pressure  should  be  ex- 
erted at  different  points  and 
movements  made.  Often  the 
free  body  c?ni  be  forced  out  of 
the  incision  by  proper  manip- 
ulations. After  suture  of  the 
incisions  in  the  capsule  and  in 
the  skin,  the  joint  should  be 
immo])ilized  for  a  week. 

Neuropathic  Arthritis. — The 
joint  changes  occurring  in  loco- 
motor ataxia  and  syringomy- 
elia, occasi(mally  also  after 
compression  and  injuries  of 
the  spiiuil  cord  and  after  in- 
flannnation  and  division  of  the 
peripheral  nerves,  are  classi- 
fied as  neuropathic  (Charcot 
joints)  and  are  ch)sely  allied 
to  those  found  in  arthritis  de- 
formans. In  neuropathic  ar- 
thritis, however,  the  destruction  is  much  more  extensive,  the  atrophy 
and  proliferation  more  pronoun.ced,  and  the  course  nuich  more  rapid. 


Fig.  272. — Arthritis  Neuropathica  (Tabica)  of 
TiiK  Ilujiip  Knkk  and  Anklk  Joints. 


722       SURGICAL   DISEASES,    EXCLUDING  INFECTIONS  AND   TUMORS 


The  symptoms  frequently  begin  acutely  after  exertion  or  slight 
trauma  Avith  a  serous  exudate  into  the  joint  and  an  extensive,  tense 
cedema  of  the  para-articular  tissues.  Neuropathic  arthritis  differs  from 
all  other  lesions  of  the  joints  in  that  it  is  ahsolutely  painless.  Accord- 
ing to  Charcot,  in  a  mild  or  benign  case  there  are  but  slight  changes 
in  the  cartilage  and  bone.  In  the  severe  or  malignant  cases  all  the 
structures  entering  into  the  formation  of  the  joint  are  involved.  An 
atrophic  and  a  hypertrophic  form  may  be  differentiated. 

In  the  former  the  ends  of  the  bones  become  small  and  atrophic, 
while  in  the  latter  proliferation  of  the  cartilage  and  bone  leads  to  the 
formation  of  marginal  osteophytes,  of  knoblike  tuberosities,  and  of 
plates  of  boiie  within  the  capsule  and  surrounding  tissues.     These  two 

forms  may  be  com- 
bined, and  as  a  rule 
they  are,  in  the 
same  case.  In  these 
cases  the  joints  in- 
volved become  flail 
as  a  result  of  the 
rapid  destruction, 
and  are  capable  of 
assuming  extreme 
abnormal  positions. 
Irregularities  in 
form  and  marked 
enlargement  and 
expansion  of  the 
ends  of  the  bones 
give  to  neuropathic 
joints  a  very  char- 
acteristic appear- 
ance, upon  which 
alone  the  diagnosis  can  often  ])e  made  (Fig.  272).  A  serous  exudate, 
i'tvr  bodies  in  llic  joint,  spontaneous  fractures  of  the  fragile  bones, 
and  pjithologieal  dislocations  complete  the  picture.  The  painless  de- 
velopment and  extent  of  the  pathological  changes,  the  extracai)sular 
fornwition  oF  ]h)iu\  jukI  llic  symptoms  of  the  ])riinary  disease  enable 
on.'  to  (■;i,sily  (liri'ci'cnl iatc  Ix'twccn  neuroj);!! hie  jii'thritis  and  arthritis 
dcrorniiins. 

X<'iiro|i;il  llic    .-irllirilis   occun-jng    in    locomotor   ataxia    is    most   com- 

'"••>'    '"    "'•'    l<i •111(1    hip    joints,    more    i-are    in    the    joints    of   the 

nppci-    cxti-cinilN .       Ill    syfingomyclia,    on    the    other    hand,    the    joints 
of   Ihr    upper  exlivMiilics   ;ir(,'   most   fiMMpiently    involved,  as   the   lesions 


J' 11..  27;i. — JioEMciKiN-lvAY  Picture  of  Cajsk  Ki^puesented  in 
Preceding  Figure. 


DISEASES  OF  JOINTS 


'23 


are,  as  a  i'nl(\  in  llio  upper  ])art  of  the  spinal  eord.     Usually  but  mn' 

joint  is  involved,  although  the  same  joint  on  the  opposite  side  may  be 

attacked. 

Trophic  disturbances,   ana'sthesia,   and   analgesia   of  the   bones   and 

joints,  fragility  of  the  bones,  and  mechanical  insults  sustained  in  the 
ataxic,  stamping  gait  of  tabetic  patients  are  im- 
portant etiological  factors  in  the  joint  lesions  de- 
veloping in  this  disease. 

The  treatment  is  similar  to  that  employed  in 
arthritis  deformans.  The  results  following  resec- 
tion, especially  resection  of  the  bones  of  the  lower 
extremitv,  are  not  as  good  as  the  results  obtained 


Fig.   274. 


Pathological  Changes   in  Elbow  Joint  in    a   Case    of   Syringomyelia. 
Healed  Fracture  of  the  Ulna. 


in  artlu-itis  deformans,  because  the  bones  are  atrophic.  Better  results 
follow  the  use  of  a  well-fitting,  mechanical  support.  If  the  destruction 
of  the  joint  is  very  extensive,  amputation  is  to  be  reconnneuded. 


(4)  ARTHRITIS   URICA,    ARTICULAR    GOUT 

Acute  and  chronic  inflammation  of  joints  form  the  most  prominent 
features  in  the  clinical  picture  of  gout.  It  is  a  constitutional  disease, 
for  the  most  part  dependent  upon  an  inherited  tendency,  in  which  the 
metabolic  processes  are  altered  and  urates  are  precipitated  from  the 
blood  and  deposited  in  the  tissues,  especially  in  the  joints  and  surround- 
ing structures,  causing  attacks  of  inflaunnation.  Chronic  alcoholism, 
high  living,  and  chronic  lead  poisoning  favor  the  development  of  gout, 
which  is  most  frequent  in  men  of  middle  and  advanced  age. 

Symptoms. — Inflammation  of  the  joints  is,  as  a  rule,  the  first  and 
most  important  symptom  of  gout,  but  changes,  of  which  chronic  inter- 
stitial nephritis  is  the  most  important,  may  develop  in  the  viscera. 
Bladder  and  kidney  stones  (urates)  are  frequent,  while  obesity,  arterio- 
sclerosis, and  diabetes  mellitus  not  infre(|uentl3'  devt'lop  later  in  the 
course  of  the  disease. 

If  the  viscera  are  not  diseased,  a  patient  suffering  with  gout  may 


724       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND  TUMORS 


attain  a  ripe  old  age;  on  the  other  hand,  chronic  nephritis,  with  its 
complications,  may  soon  prove  fatal. 

Gout  in  most  cases  has  an  acute  onset,  becoming  chronic  later; 
rarely  is  it  chronic  from  the  beginning. 

Acute  Gout. — Acute  articular  gout  usually  begins  suddenly  with 
severe  agonizing  pain,  increased  by  movement  and  pressure,  in  one  joint, 
as  a  rule,  and  with  some  fever.     Sometimes  the  attack  is  preceded  by 


Fig.  275. — AnxHRiTis  ITrica  (Goitt)  Involving  the  Intkrphalangeal  .Joints  of  the 
Little  Finger.  There  are  masses  of  urates  in  destroyed  joints,  in  the  tendons,  and 
beneath  the  .skin. 

l)ain  in  the  muscles,  weariness,  chilly  sensations,  and  indigestion.  Gout 
most  frequently  attacks  the  joints  of  the  toes  (podagra),  preferably  the 
mctatarso-phalangeal  joint  of  the  great  toe.  Circulatory  disturbances, 
which  are  frecpient  in  the  terminal  parts  of  the  body,  the  exposed  posi- 
tion of  the  toes,  and  the  frequent  occurrence  of  arthritis  deformans  in 
th(;se  joints  pi'obably  ])redispose  them  to  attacks  of  gout.  The  tissues 
around  the  joint  become  .swollen,  red,  shiny,  and  oedematous,  resembling 
diiiiciilly  iUMitc  suppurative  or  gonorrheal  arthritis.  The  attacks  fre- 
(piently  begin  in  the  middle  of  the  night,  but  toward  morning  the  pain 
and  fever  sul)si(le,  and  the  patient  sweats  profusely.  The  general  con- 
dition of  ilic  patient  remains  good.  After  one  or  two  weeks  the  night 
attaeks  gi-adually  become  less  and  less  severe,  and  the  swelling  subsides 
conq)h'tely,  without  leaving  any  noticeable  change  in  the  joint. 

When   th(i  joints   have   been   frequently   attacked,  covering   periods 


DISEASES  OF   JOINTS  725 

of  months  and  years,  the  articuhir  caitihige  may  become  infiltrated  with 
urates;  the  ends  of  the  bones,  ligaments,  and  peri-artieular  tissues  may 
become  markedly  thickened.  While  these  changes  are  taking  place  a 
number  of  smaller  joints  may  be  attacked. 

Chronic  Gout. — Patltologij. — Gout  may  become  chronic  after  the  acute 
attacks  have  been  frequently  repeated.  In  rare  cases  chronic  gout  de- 
velops vi'ithout  an  acute  stage,  and  is  accompanied  by  mild  inflammatory 
exacerbations.  Wherever  the  urates  are  deposited,  the  cartilage,  and 
later  the  bone,  synovial  membrane,  and  ligaments  may  become  necrotic. 
The  surrounding  healthy  tissue  proliferates,  forming  a  granulation 
tissue  which  surrounds  the  necrotic  tissue  and  urates,  removing  or 
encapsulating  them.  The  thickening  of  the  capsule  and  anchylosis  of 
the  joint  are  due  to  the  granulation  tissue.  Abnormal  position  of  the 
digits  and  dislocations  follow  the  progressive  destruction  of  the  articu- 
lar cartilages  and  adjacent  bone.  The  thickening  of  the  joint  becomes 
more  marked  as  the  deposit  of  urates  increases. 

When  the  capsule  of  the  joint  is  destroyed,  the  urates  may  extend  to 
structures  beneath  the  skin  or  form  encapsulated  masses  in  the  tendon 
sheaths,  bursas,  and  subcutaneous  tissues.  These  subcutaneous  collec- 
tions of  urates  give  a  peculiar,  humped  appearance  to  the  joint  involved, 
which  justifies  the  name  gout  nodules  or  "  tophi  "  which  have  been 
given  them.  The  tense  skin  covering  these  tophi  may  become  necrotic 
or  ruptured  by  injury ;  then  fistula?  form  from  which  chalky  masses  of 
urates  are  discharged,  or  they  may  become  infected,  and  suppurative 
or  putrefactive  arthritis  then  develops. 

Tophi. — The  more  or  less  painful  gout  nodules  or  tophi  are  of  diag- 
nostic importance.  These  are  round  and  covered  by  a  tense,  thin  skin; 
they  gradually  increase  in  size  until  they  may  become  as  large  as  a 
walnut  or  hen's  egg.  They  are  hard  and  movable  upon  or  firmly  adlie- 
rent  to  the  underlying  tissues  in  which  they  are  deposited.  Tophi 
occur  most  frequently  about  the  joints  of  the  hands  and  feet,  where 
they  reach  considerable  size ;  in  the  subcutaneous  tissne  of  the  scalp, 
where  they  can  be  differentiated  from  gummatous  periosteal  nodes  only 
by  the  fact  that  they  are  freely  movable;  finally,  they  occur  as  small 
nodules,  never  becoming  larger  than  a  pea  in  the  ears,  eyelids,  and 
nasal  cartilages.  The  white  contents  of  the  tophi  shine  through  the 
thin  skin  covering  them.  If  there  are  no  tophi  the  diagnosis  of  gout 
may  be  difficult,  especially  in  the  first  few  acute  attacks,  or  in  cases 
in  which  the  disease  is  chronic  from  the  beginning,  for  gonorrheal  arthri- 
tis resembles  very  closely  acute  gout;  chronic  articular  rheumati.sm  re- 
sembles chronic  gout.  The  absence  of  lynqihatic  involvement  speaks 
against  pyogenic  infections. 

Fistulae  and  marked  swelling  of  the  joint  suggest  tuberculosis.     The 


726     su'rgical  diseases,  excluding  infections  and  tumors 

chalky,  milky  character  of  the  secretion  and  the  finding  of  numerous 
fine,  uric  acid  crystals  give  a  clew  to  the  correct  diagnosis. 

The  pathological  changes  in  the  joints  are  very  characteristic.  The 
articular  cartilages  look  at  first,  even  when  there  is  but  little  involve- 
ment, as  if  they  had  been  sprinkled  over  with  plaster  of  Paris  or  chalk. 
In  time,  however,  the  white  substance  which  is  deposited  in  the  ground- 
work of  the  cartilage  penetrates  deeper  and  deeper,  causing  a  destruc- 
tion which  in  advanced  cases  may  even  extend  to  the  bone. 

The  joint  then  becomes  filled  with  crumbling,  mortarlike  masses 
which  infiltrate  the  synovial  membrane  and  capsular  ligaments.  Small 
masses  of  this  substance  are  also  found  in  the  peri-articular  tissues. 
They  are  composed  mostly  of  sodium  biurate. 

'Theories  Concerning  Cause  of  Gout. — Nothing  definite  is  known  con- 
cerning the  cause  of  the  precipitation  and  deposition  of  sodium  biurate 
in  the  tissues  and  the  way  in  which  it  occurs. 

[Futcher,  in  Osier's  "  Modern  Medicine,"  speaks  of  the  theories  of 
gout  as  follows :  ' '  Garrod  held  that  in  acute  gout  the  alkalinity  of  the 
blood  is  lessened  and  the  uric  acid  of  the  blood  is  increased,  owing  to 
the  deficient  power  of  elimination  on  the  part  of  the  kidney.  The  latter 
is  due  usually  to  organic  disease,  but  may  be  the  result  of  purely  func- 
tional disturbance.  He  attributes  the  deposition  of  sodium  biurate  in 
the  tissue  to  diminished  alkalinity  of  the  plasma,  which  is  unable  to 
hold  the  uric  acid  combination  in  solution.  During  an  acute  paroxysm 
there  is  an  accunuilation  of  the  urates  in  the  blood,  and  the  local  in- 
flammation is  caiLsed  by  their  sudden  deposition  in  crystalline  form 
about  the  joints. 

"  This  theory  has  had  many  supporters,  and  in  large  part  can  be 
accepted,  but,  as  we  have  already  seen,  any  explanation  based  on  the 
degree  of  alkalinity  of  the  ])lood  nuist  be  received  with  some  skepticism. 

"  Sir  William  Roberts  believed  that  uric  acid  normally  circulates  in 
tlie  form  of  a  soluble  quadriurate,  which  may  be  represented  by  the 
foniiiila  NalIC,,lL,N,0.,,n.CJLN.tO.„  which  is  sodium  quadriurate.  The 
sodiiun  atom  may  have  its  place  taken  by  an  atom  of  any  of  the  uni- 
valent metals.  In  the  gouty  state,  according  to  Roberts,  either  from 
(l<'fici(')it  action  of  the  kidneys  or  from  overproduction  of  urates,  the 
(piadriurate  accunnilates  in  the  blood.  The  detained  quadriurate  being 
very  unstable  and  circulating  in  a  medium  rich  in  sodium  carbonate  takes 
up  an  additional  atom  of  the  base,  and  is  converted  into  the  biurate 
as  follows:  2(NaIIC,lL,N,0,,ILC,II,N,0J  +  Na,CO,  =  4NaHCJLN,03 
-j-  (jO.^  -\-  \lj).  Tlic  l)inrate  is  very  insohible  and  less  easily  excreted 
by  the  kidneys.  It  consciincntly  accniindntcs  in  tlie  l)l()od,  and  exists 
(irst  in  a  gclalinons  ;ind  hitcr  in  the  almost  insoluble  crystalline  form. 
11  is  Ihcn  that  ])iV('ii)itation  is  imminent  or  actually  takes  place.     This 


DISEASES   OF   JOINTS  727 

is  apt  to  occur  where  the  eireulatioii  is  poor  and  the  teniperatiuM^  lnw 
ami  regions  in  which  the  lymph  contains  a  reUitively  liiuh  percentage 
of  sodium  chlorid,  as  in  the  synovial  sheaths.  This  theory  has  met  with 
opposition  from  various  quarters,  and  particularly  on  the  part  of  Tunni- 
cliflfe  and  Rosenheim. 

"  Ebstein  holds  that  the  local  manifestations  of  gout  are  due  to 
nutritive  disturbances  which  lead  to  necrosis.  He  found,  after  a  study 
of  many  of  the  affected  tissues  in  gout,  that  one  change  is  common  to 
them  all,  independent  of  the  urate  crystallization,  and  that  is  a  necrosis 
of  the  parts  in  which  such  deposition  takes  place.  He  believes  that  this 
necrosis  is  primary  and  that  it  is  as  characteristic  as  the  biurate  de- 
posit. Both  changes  nuist  coexist  in  any  tissue  in  order  to  constitute 
a  true  gouty  lesion,  and  he  has  found  such  lesions  in  the  kidneys,  in 
hyaline  and  fibro-cartilage,  and  in  tendons  and  connective  tissue.  He 
calls  attention  to  the  early  stages  of  the  necrotic  process,  in  which  he 
finds  no  deposition  of  the  biurates,  and  consequently  maintains  that  a 
nutritive  ti.ssue  disturbance  is  the  primary  factor,  and  uratic  depo- 
sition a  secondary  one,  in  the  gouty  process,  the  latter  not  occurring 
imtil  death  of  the  tissues  takes  place.  Von  Noorden  supports  Ebstein 's 
A'iews,  and  believes  that  the  tissue  necrosis  is  due  to  the  action  of  a 
special  ferment.  In  recent  years  attention  has  been  attracted  to  the 
xanthin  or  purin  bases  as  a  possible  cause  of  gout.  Kolisch  found  that 
although  the  uric  acid  excretion  is  diminished,  yet  the  total  output  of 
the  alloxuric  or  purin  bodies  was  increased.  He  believed  that  the 
xanthin  bases  normally  are  finally  oxidized  into  uric  acid  in  the  kidneys, 
but  that  in  gout  the  kidneys  are  diseased  and  their  power  to  oxidize 
the  xanthin  bases  is  consequently  impaired.  His  results  were  obtained 
by  methods  shown  later  to  be  inaccurate,  and  Siilzer,  Laquer,  and  Mag- 
nus-Levy failed  to  confirm  them.  Whatever  part  the  xanthin  bases  may 
subsequently  be  shown  to  play  in  the  etiology  of  gout,  up  to  the  present 
time  they  have  not  been  shown  to  exert  an  important  influence.  Un- 
doubt(Hlly  some  of  the  xanthin  bases  are  definitely  toxic.  Kolisch  and 
Croftan  have  produced  arterial  and  renal  lesions  by  injecting  hypo- 
xanthin  into  animals.  AValker  Hall  confirmed  these  results  and  also 
produced  parenchymatous  changes  in  the  liver  by  long-continuccl  injec- 
tions of  hypoxanthin. "] 

A  chronic  proliferation  of  the  connective  tissues,  which  encapsulates 
the  necrotic  tissue  and  urates,  follows  the  irritation  resulting  from  the 
necrosis  of  the  tissues. 

Treatment. — The  greater  part  of  the  treatment  of  gout  belongs  to 
internal  medicine.  An  attempt  should  be  made  to  prevent  the  excessive 
formation  of  uric  acid  by  regulating  the  diet,  by  exercising,  bathing, 
and  drinking  of  alkaline  waters. 


728      SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND   TUMORS 

In  acute  arthritis  the  involved  joint  should  be  wrapped  in  cotton 
or  sheet  wadding,  immobilized,  and  elevated.  Morphin  may  be  required 
to  control  the  pain ;  frequently  colehicum,  sodium  salicylate,  and  other 
drugs  are  of  value.  IMoist  compresses  have  a  favorable  influence  upon  the 
pain.  They  should  not  be  used,  however,  when  there  are  subcutaneous 
nodes,  as  they  macerate  the  skin  and  may  lead  to  the  formation  of 
fistulie. 

The  only  operative  procedures  which  should  be  considered  are  ex- 
cision of  large,  troublesoip.e  tophi  situated  in  the  soft  tissues  and  ampu- 
tation of  deforined  and  nmimed  fingers  and  toes,  especially  if  there  is 
suppuration.  Curetting  out  of  the  masses  of  urates  is  not  very  often 
successful,  as  the  tissues  are  rarely  able  to  form  good  healthy  granu- 
lation tissue  and  to  heal,  and  new  masses  may  be  deposited  very  soon. 
Not  infrequently  a  new  mass  is  deposited  with  acute  symptoms  after  an 
old  one  has  been  curetted  away.  Riedel  has,  however,  observed  a  per- 
manent recovery  in  two  eases  in  which  the  tophi  and  the  capsular  liga- 
ment were  removed  from  the  metatarso-phalangeal  joint  of  the  great  toe. 

(d)  DISEASES    OF    THE    JOINTS    OCCURRING    IN    BLEEDERS 

Characteristic  lesions  of  the  joints  are  frequent  in  hamiophilia,  a 
disease  in  which  there  is  a  tendency  to  haemorrhages  within  the  joints. 
These  lesions  may  occur  even  in  childhood,  and  develop  in  one  or  many 
joints  after  an  insignificant  trauma  or  some  physical  effort.  The  knee 
joint  is  involved  most  frequently.  If  the  patient  does  not  die  from 
haemorrhage  from  some  other  source,  marked,  often  serious,  changes 
gradually  develop  in  the  joint  involved. 

Pathology. — According  to  Konig  there  are  three  stages  in  the  patho- 
logical changes,  the  first  of  which  is  a  ha^marthrosis.  Symptoms  of  fluid 
within  the  joint,  resembling  closely  those  of  inflanniiatory  hydrops, 
develop  i-apidly  with  slight  or  severe  pain,  sometimes  with  elevation  of 
temperature.  After  soiik^  days  discoloration  of  the  skin  and  ecchy- 
moses  indicate  the  nature  of  tli(>  exudate.  If  the  joint  is  protected  the 
exudate  may  be  rapidly  and  completely  absorbed.  If,  however,  the  exu- 
date is  large,  a  niunlx  r  of  weeks  may  be  re(|uired  for  complete  absorp- 
tion. There  may  be  no  disturbance  of  function  after  the  exudate  is 
absorbed.  Soiiiejimes  patients  recover  from  a  number  of  attacks  of  this 
char'Mctei-  without  any  limitation  of  motion,  (iocht  observed  one  case 
in  which  there  had  been  foi'ty-five  distinct  attacks,  and  still  the  function 
of  the  knee  joint  was  good. 

Sometimes  earlier,  sometimes  later,  the  disease  passes  into  the  second 
stage,  that  of  general  chronic  inflammation  or  I'xiiiarllirifis  (Konig). 
The  swelling  of  the  joint   then   does  not  subside  completely   after  an 


DISEASES   OF   JOINTS  729 

attack.  Thickening  of  the  capsule,  crepitation  when  the  joint  is  moved, 
severe  pain,  limitation  of  motion,  and  contractures  indicate  that  the 
pathological  changes  are  extensive  and  profound.  The  fibrin  coagulates 
and  becomes  organized,  maintaining  a  chronic  inflammation  of  the  joint 
and  causing  pressure  necrosis  of  the  articular  cartilages,  as  in  tuber- 
culous arthritis.  If  the  joint  is  opened  (post  mortem)  there  will  be 
found  a  seroha^morrhagic  exudate;  a  thickened  and  indurated  capsule; 
brownish,  hypertrophied  synovial  villi  in  the  recesses  of  the  joint;  and 
at  the  margins  of  the  articular  cartilagas  flat  masses  of  coagulum,  often 
of  the  thickness  of  the  finger,  and  irregular  defects  in  the  cartilages  due 
to  pressure  of  these  pieces  of  coagulum.  Clinically  it  is  scarcely  pos- 
sible to  distinguish  this  form  of  arthritis  from  the  granulating  form 
of  tuberculous  arthritis  or  from  the  transitional  form  between  tuber- 
culous hydrops  and  the  latter. 

The  third  stage,  characterized  by  regressive  changes,  leads  to  the 
development  of  contractures.  The  organized  masses  of  fi1)rin  form  an 
organic  fibrous  union  between  the  eroded  and  ulcerated  articular  sur- 
faces, while  the  chronically  inflamed  capsule  and  peri-articular  tissues 
contract.  Contractures  and  anchylosis,  not  infrequently  accompanied 
by  dislocations,  develop.  The  thickening  of  the  tissues  about  the  joint 
is  the  more  pronounced  as  there  is  more  or  less  muscular  atrophy.  The 
thickening  about  the  joint  is  not  due,  however,  as  it  often  appears  to 
be,  to  enlargement  of  the  ends  of  the  bone,  but  to  the  thickening  of  the 
capsule.  Even  in  this  stage  the  diagnosis  of  tuberculous  arthritis  is 
often  made. 

These  three  stages  do  not  occur  in  each  patient.  In  many  cases  the 
haemorrhage  ceases  before  there  are  any  marked  changes  in  the  joint, 
while  in  others  the  haemorrhages  are  repeated  again  and  again  until  the 
deformities  and  destructive  lesions  characteristic  of  the  third  stage 
develop. 

In  making  a  diagnosis  other  symptoms  of  haemophilia  are  naturally 
important.  The  family  and  previous  history  of  the  patient  should  be 
carefully  elicited,  as  the}^  are  of  the  greatest  importance.  As  a  rule, 
haemophiliacs  are  pale  children  or  young  adults  of  the  male  sex.  Be- 
sides tuberculous  arthritis,  ha-marthrosis  following  the  rupture  of  a 
myeloid  sarcoma  into  the  joint  should  also  be  considered  in  the  dif- 
ferential diagnosis.  In  these  eases  the  X-rny  findings  are  of  great 
value. 

The  treatment  is  limited  to  immobilization  and  compression  of  the 
joint  involved,  to  the  use  of  the  weight  and  pulley,  or  of  an  extension 
apparatus  (Gocht)  to  correct  the  contractures.  Forcible  reduction  and 
operative  procedures  should  never  be  employed.  The  latter  are  always 
associated  with  the  dangers  of  death  from  haemorrhage.  Aspiration  of 
47 


730      SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 

the  larger  exudates  with  subsequent  washing  out  of  the  joint  with  a 
three  per  cent  solution  of  carbolic  acid  (Konig)  may  be  done  without 
danger.  Concerning  the  local  and  general  treatment  with  gelatin  vide 
p.  679. 

Literature. — Barth.  Die  Entstehung  und  das  Wachstum  der  freien  Gelenkdrper. 
Arch.  f.  klin.  Chir.,  Bd.  56,  1898,  p.  507. — -Bcnnecke.  Beitrag  zur  Anatomie  der  Gicht. 
Arch.  f.  khn.  Chir.,  Bd.  66,  1902,  p.  658. — Borchard.  Die  Knochen-  und  Gelenker- 
krankungen  bei  der  Syringomyehe.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  72,  1904,  p.  513. 
— Burner.  Klin.  u.  path.-anat.  Beitriige  zur  Lehre  von  den  Gelenkmausen.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  70,  1903,  p.  SdS.—Bildinger.  Die  Behandlung  der  chron.  Ar- 
thritis mit  Vaselininjektionen.  Wien.  klin.  Wochenschr.,  1904,  No.  17. — E.  Frdnkel. 
Ueber  chron.  ankylosierende  Wirbelsaulenversteifung.  Fortschr.  a.  d.  Geb.  d.  Rontgen- 
strahlen,  Bd.  7,  1904. — Gocht.  Ueber  Blutergelenke  u.  ihre  Behandlung.  Chir.-Kongr. 
Verhandl.,  1899,  II,  p.  359.— -Graf.  Ueber  die  Gelenkerkrankungen  bei  Syringomyehe. 
Beitr.  z.  khn.  Chir.,  Bd.  10,  1893,  p.  517. — Heiligcnihal.  Die  chron.  Steifigkeit  der 
Wirbelsaule  (Bechterew)  u.  die  chron.  ankylosierende  Entziindung  der  Wirbelsaule 
(Striimpell),  Spondylose  rhizomeUque  (P.  Marie).  Zentralbl.  f.  d.  Grenzgeb.,  1900,  p.  11. 
— Janssen.  Zur  Kenntnis  d.  Artliritis  chronica  ankylo-poetica.  Mitteil.  aus  d.  Grenz- 
geb., Bd.  12,  1903. — Konig.  Zur  Geschichte  der  Gelenkkorper  in  den  Gelenken.  Chir.- 
Kongr.  Verhandl.,  1899,  II,  p.  1; — Die  Gelenkerkrankungen  bei  Blutern  mit  besonderer 
Berik'ksichtigung  der  Diagnose,  v.  Volkmanns  Samml.  klin.  Vortr.,  N.  F.,  1892,  No.  36. 
— Kredel.  Die  Arthropathien  und  Spontanfrakturen  bei  Tabes,  v.  Volkmanns  Samml. 
klin.  Vortr.,  1888,  No.  309. — Linser.  Beitrag  zur  Kasuistik  der  Blutergelenke.  Beitr. 
z.  klin.  Chir.,  Bd.  17,  1896,  p.  105. — Mermingas.  Beitrag  zur  Kenntnis  der  Bluter- 
gelenke. Arch.  f.  klin.  Chir.,  Bd.  68,  1902,  p.  l^S.—Riedel.  Die  Entfernung  der  Urate 
un<l  der  Gelenkkapsel  aus  tlem  an  Podagra  erkrankten  Grosszehgelenke.  Deutsche  med. 
Wochenschr.,  1904,  p.  1265. — Rosenhach.  Zur  pathcd.  Anatomie  der  Gicht.  Virchows 
Arch.,  Bd.  179,  1905,  p.  359. — Rotter.  Die  Arthropathien  bei  Tabiden.  Arch.  f.  klin. 
('hir.,  Bd.  36,  1887,  p.  1. — Schmieden.  Ein  Beitrag  zur  Lehre  von  den  Gelenkmausen. 
Arch.  f.  klin.  Chir.,  Bd.  62,  1!)00,  p.  542. — Schuchardt.  Die  Krankheiten  der  Knochen 
und  Gelenke.  Deutsche  Chir.,  1899. — Schfdler.  Chirurg.  Mitteil.  iiber  die  chronisch 
rheiunatischen  Gelenkentziingen.  Chir.  Kongr.-Verhandl.,  1892,  II,  p.  404. — Stempel. 
Die  Ilamophilie.  Sammelreforat.  Zentralbl.  f.  d.  Grenzgeb.,  1900,  p.  721. — v.  Volk- 
viann.  Die  Krankheiten  der  Bewegungsorgane.  v.  Pitha-Billroths  Handb.  der  Chir., 
Bd.  2,  2.  Abt.,  Erlangen,  \S12.—Wulk}wff.  Ueber  Arthritis  tleformans.  Verhandl.  d. 
deutsch.  pathol.  Gesellsch.,  Sept.,  1905,  p.  229. — Ziegler.  Subchondrale  Veriinderung 
der  Knochen  bei  Arthritis  deformans.     Virchows  Arch.,  Bd.  70,  1877. 


(e)  GANGLION 

Caiiglion  is  a  term  given  to  a  localized  cystic  formation  which  de- 
velops fre(|ueiitl,\'  in  the  tissues  of  the  capsule  of  joints,  occasionally 
fi'om  a  tendon-sheath  or  tendon. 

Occurrence. — Joint  ganglia  ai-e  found  most  fi'ecjuently  upon  the  dor- 
sal surface  of  the  wrist,  in  the  dejji-cssion  l)et\veen  tlie  tendons  of  the 
cxten.sor-  indicis  and  the  extensor  car})i  radialis  brevis.  As  a  ganglion 
dcveldps  in  this  situation  it  pushes  the  ligamehtum  carpi  dorsale  in 
front  of  it.     (langiia  ai'e  less  frcMpient  upon  the  llexor  side  of  the  wrist 


DISEASES   OF   JOLNTS 


731 


joint.  \Yhen  they  develop  here  they  are  usually  situated  beneath  the 
radial  artery,  beside  the  tendon  of  the  tiexor  earpi  radialis.  They 
also  occur  on  the  dorsum  of  the  foot,  and  occasionally  about  the  knee 
joint. 

The  thinned,  translucent  connective  tissue  of  the  capsular  liizament 
forms  the  wall  of  the  sac,  which  contains  a  clear,  transparent  colloid 
or  gelatinous  substance.  After  unsuccessful  attempts  at  cure  the  sac 
contracts  firm  adhesions  with  the  neighbor- 
ing tendon  sheaths.  The  cyst  is  attached  to 
its  point  of  origin  by  a  broad  base  or  short 
pedicle,  and  is  separated  from  the  cavity  of 
the  joint  by  a  delicate  membrane,  the  re- 
mains of  the  joint  capsule,  unless  it  has 
already  ruptured  into  the  joint.  While  old 
cysts  are  usually  unilocular,  recent  cysts  are 
multilocular  and  contain  upon  their  inner 
Avail  prominent  projecting  folds.  Even  in 
the  Avails  of  unilocular  cysts  small  recesses 
or  cavities  can  be  demonstrated  microscop- 
ically. 

Etiology. — Ganglia  were  formerly  con- 
sidered to  be  due  to  the  constriction  of  an 
evaginated  portion  of  the  synovial  mem- 
brane; in  other  Avords,  they  Avere  regarded 
as  synovial  hernia.  This  explanation  Avas 
suggested  by  Gosselin  in  1852.  ]\Iore  re- 
cently Falkson  and  Riedel,  basing  their 
observations  upon  clinical  experience,  have 
shoAvn  that  the  cysts  originate  Avithin  the  tis- 
sues of  the  capsular  ligament  and  not  within 

the  sj'novial  membrane.  Virchow  and  von  Volkmann  had  previously 
suggested  that  this  might  be  the  case.  The  histological  iuA'estigations 
of  Ledderhose,  and  later  those  of  Ritschl,  Thorn,  and  Payr,  have  verified 
the  clinical  findings  of  Falkson  and  Riedel.  They  have  found  that  these 
cysts  are  the  result  of  degenerative  changes  in  the  capsular  and  para- 
articular tissues  (more  rarely  in  the  tendinous  and  paratendinous  tis- 
sues) resulting  in  the  formation  of  a  gelatinous  substance,  the  contents 
of  the  ganglion.  Nutritional  disturbances,  caused  apparently  by  an 
obliterating  endarteritis  of  traumatic  origin,  precede  the  degenerative 
changes.    Later  several  of  these  small  cysts  fuse  to  form  one  large  one. 

Ganglia  occur  most  connuonly  in  young  people,  during  and  after 
the  age  of  puberty,  but  may  develop  even  at  an  advanced  age.  They 
are  more  frequent  in  the  female  than  in  the  male. 


Fig.    276. — (jAnglion    on    the 
Dorsum  of  the  Foot. 


732      SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 

Symptoms. — The  first  symptoms  are  indefinite  for  a  long  time.  Some- 
times impairment  of  motion,  at  other  times  neuralgic  pains  direct  the 
attention  of  the  patient  to  the  swelling,  which  is  supposed  to  be  the 
result  of  a  sprain.  As  a  matter  of  fact,  ganglia  are  frequently  caused 
by  insignificant  lacerations  or  injuries  due  to  overexertion  of  the  wrist 
in  piano  playing,  roAving,  fencing,  etc.  The  cyst  slowly  enlarges,  but 
rarely  becomes  larger  than  a  walnut.  Frequently  it  remains  of  the 
same  size,  and  often  becomes  somewhat  smaller  spontaneously.  Not 
infrequently  the  smaller  ganglia  subside  completely  without  any  treat- 
ment. A  slight  limitation  of  motion  may  be  the  only  symptom  of  even 
the  larger  ganglia. 

The  appearance  of  a  ganglion  is  very  characteristic.  The  smooth 
or-  uneven  surface  of  the  cyst,  which  is  firmly  attached  to  the  surround- 
ing structures  or  is  slightly  movable  when  attached  by  a  pedicle,  is  cov- 
ered by  normal  skin.  The  smaller  cysts  may  be  hard  and  non-fluctu- 
ating.    Fluctuation  can  be  easily  elicited  in  the  larger  cysts. 

The  diagnosis  can  be  made  upon  the  position  of  the  swelling  and 
the  characteristics  above  given.  It  is  important  to  differentiate  ganglia 
from  hygromas  of  the  synovial  sheaths  and  bursa?. 

Treatment. — In  the  treatment  an  attempt  should  first  be  made  to 
cure  ganglia  by  non-operative  methods.  The  author  has  repeatedly 
cured  ganglia  by  rupturing  them  by  one  blow  with  a  wooden  hammer, 
or  by  binding  a  lead  button  over  the  swelling  until  the  wall  of  the  cyst 
has  become  thinned  and  has  ruptured  subcutaneously.  Recurrences — 
large  cysts  developing  from  small  accessory  ones — are  frequent  after 
this  method  of  treatment.  If  the  treatment  is  repeated  a  permanent 
cure  may  be  obtained. 

If  the  non-operative  treatment  has  been  unsuccessful,  an  operation, 
which  should  be  performed  with  the  greatest  aseptic  precautions,  should 
be  advised.  In  the  comi)lete  removal  it  may  be  necessary  to  open  the 
joint  or  synovial  sheath,  and  even  the  mildest  infection  may  be  followed 
by  most  serious  results.  The  operation  should  always  be  performed 
under  artificial  ischa'mia,  as  in  this  Avay  the  anatomical  relations  may 
b(!  bcttci-  exposed,  and  the  fir.gers  slionid  not  come  in  contact  with  the 
wound. 

Recurrence  follows  extiri)ati()n  only  when  a  part  of  the  pedicle  or 
some  of  the  diseased  tissue  of  the  capsule  is  left. 

Subcutaneous  discission  with  the  tenotome,  aspiration  and  subse- 
quent injection  with  alcohol  and  carbolic  acid,  and  incision  combined 
willi  laiii|»(iiiiiig  are  soin('tim(\s  but  not  unironiily  successful. 

LiTKHAT'iuK. — Franz.  Ueber  GiinfjjruMi  in  dor  llohlliaud.  Arch.  f.  klin.  Chir., 
]i.l.  70,  HHKi,  p.  f)T.\.~-Kultmr.  Zur  Kliiiik  der  Ganglien.  Zentialbl.  f.  Chir.,  190r), 
J).   1333. — Lcdderhose.     Die  Aetiologie  der  karpalen  Ganglien.     Deutsche  Zeitschr.  f. 


DISEASES   OF   BONE  733 

Chir.,  B(l.  37,  1893,  p  102. — Pc'/r.  Beitragc  zum  foinorcn  B:ui  unci  dor  Entstehung 
der  karpalen  Ganglien.  Deutsche  Zeifsohr.  f.  Cliir.,  Bd.  49,  1899,  p.  :i'29.—RitschL 
Beitrag  ziir  Pathogenese  der  (ianglien.  Beitr.  z.  klin.  (Jhir.,  Bd.  14,  1895,  j).  5.57. — 
Thorn.     Ueber  die  Entstehung  der  Ganglien.     Arch.  f.  klin.  Chir.,  Bd.  52,  189G,  p.  593. 


CHAPTER    VII 

DISEASES    OF    BONE 

(a)  CONGENITAL  DEFECTS  IN  SKELETAL  DEVELOPMENT 

There  are  a  number  of  malformations  cine  to  the  failnre  of  develop- 
ment of  bones.  These  may  be  due  in  part  to  arrested  (aplasia),  in  part 
to  the  inhibition  of  normal  development.  Examples  of  such  malfor- 
mations are  complete  or  incomplete  absence  of  bones  of  the  extremities, 
of  the  clavicle  and  sternum,  or  defects  in  the  skull  bones  and  vertebrae 
and  fissures  in  the  maxilla.  The  loss  of  distal  parts  of  the  extremities 
due  to  constriction  by  amniotic  bands  is  also  classified  with  the  failures 
in  development.  ]\Ialformations  may  be  due  to  excessive  development. 
The  most  common  examples  are  supernumerary  phalanges,  metacarpal 
and  metatarsal  bones,  cervical  ribs  and  additional  vertebrae  (in  tail 
formation). 

Atrophy  of  the  bones  (the  result  of  intra-uterine  lesions  or  fractures), 
the  different  hypoplastic  and  hypertrophic  conditions  of  bone  which  are 
present  at  birth  or  develop  soon  after  are  frequently  the  causes  of 
malformations. 

Hypoplasia  may  affect  the  entire  body,  in  which  case  a  dwarf  re- 
sults, or  a  portion  of  it  only,  giving  rise  then  to  imperfect  formation 
of  single  parts  or  organs,  such  as  hypoplasia  of  the  extremities  (micro- 
melia)   and  congenital  skeletal  atrophy  (so-called  fnptal  rickets). 

Foetal  Chondrodystrophy  and  Periosteal  Dystrophy. — ^There  are  two 
varieties  of  foetal  rickets.  In  the  one  (cartilaginous  dysplasia,  foetal 
chondrodystrophy  of  Kaufmann,  ftetal  cretinism  of  Ilorsley)  there  is 
impaired  endochondral  bone  formation,  while  the  periosteal  bone  for- 
mation is  normal.  The  bones  are  therefoi-e  thick  and  hard,  but 
shortened  and  distorted.  In  the  other  (periosteal  dystrophy)  the  peri- 
osteal bone  formation  is  interfered  Avith,  while  endochondral  bone  for- 
mation is  normal,  and  the  bones  are  malformed,  soft,  and  fragile. 
Hypertrophy  of  bones  may  be  the  cause  of  general  (macrosomia)  or 
partial  giant  growth.  .  The  latter  may  be  confined  to  parts  of  the  feet 
or  hands. 

Bone  Changes  in  Cretinism. — The  more  or  less  imperfect  development 
of  bones  in  cretinism,  a  disease  occurring  endemically  in  yoimg  people 


734      SURGICAL  DISEASES,   EXCLUDING  INFECTIONS  AND  TUMORS 

living  in  goiter  regions,  is  due,  as  ai-e  the  other  symptoms  of  the  disease 
(myxcedema,  hypoplasia  of  the  genitalia),  to  a  disturbance  of  the  func- 
tion of  the  thyroid  gland,  which  is  either  absent,  atrophied,  or  altered 
in  structure  (goiter).  The  relationship  between  cretinism  and  the  thy- 
roid gland  has  been  demonstrated  experimentally  (Hofmeister,  von 
Eiselsberg).  In  cretinism  the  epiphyseal  cartilages  do  not  become 
ossified  for  a  long  time,  but  they  are  unable,  because  of  regressive 
changes,  to  produce  bones  of  normal  length.  The  centers  of  ossification 
in  the  epiphyses  develop  late.  If  the  feeding  of  thyroid  gland  or  thy- 
roid preparations  is  begun  early  and  continued  the  symptoms  may  im- 
prove and  the  growth  of  the  bones  may  be  increased. 

,  Literature. — v.  Eiselsberg.  Die  Krankheiten  der  Schilddruse.  Deutsche  Chlr., 
1901  Kretinismus,  p.  197. — Nasse.  Die  Krankheiten  der  unteren  Extremitiiten. 
Deutsche  Chir.,  1878,  Riesenwuchs  des  Fusses,  p.  1. — Schuchurdt.  Die  Krankheiten  der 
Knochen  und  Gelenke.  Deutsche  Chir.,  1899,  p.  58. — P.  Vogt.  Die  Krankheiten  der 
oberen  Extremitiiten.     Deutsche  Chir.,  1881. 


(b)  ATROPHY  OF  BONE 

Atrophy  of  bone  occurs  in  the  form  of  lacunar  resorption.  The 
resorption  in  diseased  bones  is  not  actually  in  excess  of  that  occurring 
in  normal  developing  bone  (Pommer),  but  only  relatively  so,  as  new 
bone  is  not  formed  to  replace  that  lost  by  resorption  (Schuchardt). 

Concentric  and  Eccentric  Atrophy  of  Bone. — Sometimes  the  resorption 
begins  upon  the  surface  of  the  bone  and  extends  inward,  while  at  other 
times  it  begins  in  the  medulla  and  advances  outward.  In  the  former 
(concentric  atrophy)  the  bone  becomes  thinner  and  smaller,  while  in 
the  latter  (eccentric  atrophy)  the  medullary  cavity,  the  Haversian 
canals,  and  the  spaces  in  the  spongy  bone  become  enlarged  as  the 
trabeculii'  of  bone  disappear  and  fat  accunnilates  in  these  enlarged 
spaces.  ]['  the  entire  bone  becomes  porous  and  light  the  condition  is 
known  as  osteoporosis;  if  decayed  and  fragile,  as  osteopsathyrosis; 
if,  after  consideral)Ie  loss  of  calcium  salts,  it  becomes  flexible,  as 
o.sl(omalaci(i. 

The  fragility  of  atrophic  bones  is  of  greatest  surgical  interest,  as  the 
diseased  l)ones  may  be  fractured  by  very  slight  injuries,  even  by  bear- 
ing tlie  body  weiglit  upon  them. 

Delayed  Repair  After  Fracture. — Repair  of  such  fractures  is  often 
delayed;  non-union  is  frequent,  except  in  the  pathological  fractures 
oeciii-riiig  in  neuropathic  atrophy,  as  there  is  but  little  tendency  to  the 
formation  of  callus.  For  the  same  reason  it  is  often  difficult  to  obtain 
union  after  operation  upon  joints  in  which  anchylosis  (e.  g.,  paralyzed 
extremities)  is  useful  and  desired. 


DISEASES  OF   BONE  735 

Causes  of  Atrophy  of  Bone. — There  are  a  number  of  different  causes 
of  atrophy  of  bone.  Some  of  these  may  be  local,  the  majority  are  gen- 
eral. 

Among  the  local  causes  are  aneurysms,  tumors,  and  echinococcus 
cysts.  These  develop  either  without  the  bone  and  later  extend  to  it, 
producing  a  pressure  necrosis  of  the  cortex,  or  within  the  bone,  and 
as  they  enlarge  cause  a  pressure  necrosis  and  expansion  of  the  cortex, 
finally  rupturing  through  it.  The  atrophy  following  long-continued 
non-use  (atrophy  of  disuse)  is  also  placed  in  this  class.  Disu.se  atrophy 
is  most  frequent  in  the  bones  of  the  extremities,  which  have  been  thrown 
out  of  function  for  a  long  time  or  permanently  as  the  result  of  severe 
injuries,  inflammatory  lesions,  paralyses,  or  after  fractures  with  vicious 
union  in  which  the  extremity  cannot  be  used  to  support  the  weight 
of  the  body.  The  conical  form  which  the  bones  in  an  amputation 
stump  assume  vaay  be  prevented  if  an  artificial  limb  is  used  and  weight 
is  borne  upon  the  stump. 

Nutritional  and  trophic  disturbances  are  the  most  important  of  the 
general  causes.  In  old  age  a  general  osteoporosis  occurs,  and  frac- 
tures, especially  of  the  neck  of  the  femur,  following  insignificant  in- 
juries and  curvature  of  the  spine  are  frequent.  Atrophy  of  the  alveolar 
borders  of  the  jaws  following  extraction  of  the  teeth,  and  shortening 
of  the  lower  parts  of  the  face  are  the  best-known  examples  of  this  form 
of  atrophy  of  bone.  Superficial,  sometimes  perforating,  defects  of  the 
bones  of  the  skull  may  result  from  senile  atrophy.  Similar  changes 
occurring  in  young  people  sufit'ering  from  chronic  infectious  diseases 
are  known  as  marantic  atrophy  of  bone. 

If  the  cause  of  the  atrophy  depends  upon  some  disease  of  the 
peripheral  nerves  or  central  nervous  system,  it  is  called  neurotic  atrophy. 
This  form  of  atrophy  is  due  wholly  or  in  part  to  the  loss  of  trophic  influ- 
ences. It  is  indicated  in  growing  bones  by  shortening,  in  fully  developed 
bones  by  osteoporosis,  sometimes  accompanied  by  osteomalacia.  Of  course 
if  there  is  paralysis,  disuse  is  also  an  etiological  factor.  The  pure  form 
of  neurotic  atrophy  is  found  only  in  diseases,  such  as  syringomyelia, 
locomotor  ataxia,  and  paretic  dementia,  in  which  the  use  of  the  extremi- 
ties is  not  interfered  with.  Painless,  spontaneous  fractures  are  frequent 
in  this  form  of  atrophy.  Often  the  repair  of  these  fractures  is  rapid,  and 
excessive  callus  is  formed,  as  the  bones  are  analgesic  and  mechanical 
irritation  of  the  fractured  ends  is  not  prevented  by  pain  as  in  ordinary 
fractures. 

Sudeck  has  shown  by  Roentgen-ray  pictures  tliat  the  bony  atrophy 
developing  acutely  after  injuries  and  inflannnation  is  due  to  trophic 
disturbances.  The  rapid  loss  of  the  contour  of  the  affected  bone  in 
these  cases  cannot  be  explained  by  disuse  alone.     It  is  probably  of  a 


736       SURGICAL   DISEASES,   EXCLUDING  INFECTIONS   AND   TUMORS 

reflex  nature,  similar  to  the  muscular  atrophy  occurring  in  arthritis 
(vide  p.  655). 

After  the  primary  lesion  has  healed  the  atrophy  may  gradually 
subside.  In  tuberculous  arthritis  it  is  often  difficult  to  determine 
whether  the  indistinct,  clear  shadows  in  the  X-ray  pictures  correspond 
to  tuberculous  foci  or  to  atrophic  bone.  If  due  to  atrophy  the  shadows 
will  be  much  more  extensive. 

Idiopathic  Osteopsathyrosis. — Idiopathic  osteopsathyrosis  is  a  pecul- 
iar but  rare  form  of  atrophy  of  bone,  the  cause  of  which  is  unknown. 
The  disease,  characterized  by  frequent,  sometimes  nuiltiple  fractures, 
develops  in  early  childhood.  Schuchardt  writes  of  a  girl  twelve  years 
of  age  who  had  sustained  forty-one  fractures  in  ten  years,  the  first 
o6e  occurring  when  she  was  two  years  old.  In  a  large  proportion  of 
eases  the  disease  is  inherited. 

Inflammatory  atrophy  of  bone,  the  result  of  rarefying  osteitis,  is 
found  in  pyogenic,  tuberculous,  and  gummatous  lesions  of  bone  (see 
p.  425). 

Literature. — Adlcr.  Ueber  tabische  Knochen- und  Gelenkerkrankungen.  Sammel- 
referat  mit  Lit.  Zentralbl.  f.  d.  Grenzgeb.,  1903,  p.  849. — Schlesinger.  Die  Erkrank- 
ungen  der  Knochen  und  Gelenke  bei  Syringomyelie.  Zentralbl.  f.  Grenzgeb.,  1901, 
p.  625. — Schuchardt.  Die  Krankheiten  der  Knochen  und  Gelenke.  Deutsche  Chir., 
1899,  pp.  58-83. — Sudeck.  Ueber  die  akute  (reflektorische)  Knochenatrophie  nach 
Entziindungen  und  Verletzungen  an  den  Extremitaten  und  ihre  klinischen  Erschein- 
ungen.  Fortschritte  auf  dem  Gebiete  der  Rontgenstrahlen,  Bd.  5,  1902,  p.  277; — 
Zur  Altersatrophie  (einschl.  Coxa  vara  senium)  und  Inaktivitatsatrophie  der  Knochen. 
Ibid.,  Bd.  3,  1900,  p.  201. 


(c)  HYPERTROPHY  OF  BONE 

Hypertrophy  of  bone  is  frequently  the  result  of  inflammatory  proc- 
esses, which  lead  (especially  in  syphilis)  to  the  formation  of  hyperos- 
toses, in  periosteal  tumors  and  in  ulcers  adjacent  to  bone  to  the  forma- 
tion of  osteophytes,  in  suppurative  osteomyelitis  to  the  formation  of  the 
involucrum,  and  in  fractures  to  callus  formation.  Suppurative  and 
tuberculous  lesions  of  bone  occurring  during  the  period  of  growth  often 
h'ad  to  an  increase  in  length  of  the  bone  involved. 

Leontiasis  Ossea. — There  are  but  two  forms  of  independent  hyper- 
tropliy  of  bone,  and  these  are  rare:  Leontiasis  ossea  and  acromegaly. 
The  disease  called  leontiasis  ossea  by  Virchow  begins  in  young  people 
witiiout  any  distinct  symptoms,  and  gradually  leads  after  a  number  of 
yciirs  to  a  symmetfical  thickening  and  induration  of  the  bones  of  the 
rac(!  and  skull.  The  changes  usually  begin  in  tbe  niiixilla\  The  skele- 
ton of  llic  face  gi-adualiy  becomes  transfoi'nied  into  a  heavy,  bony  mass, 
and  all  semblance  to  normal  human  features  is  lost.     The  symptoms 


DISEASES  OF   BONE 


737 


Fig.  27 


-Leomiasis  Ossea. 


which  follow  the  painless  proliferation  and  hypertrophy  of  the  bones 
are  secondary,  as  the  skull  bones  of  from  4  to  5  cm.  in  thickness 
press  upon  the  brain,  causing  head- 
aches, convulsions,  paralyses,  and  men- 
tal disturbances.  The  thickening  of  the 
facial  bones  occludes  the  nasal  passages, 
forces  the  eyes  out  of  the  orbit,  caus- 
ing exophthalmos,  and  destroys  the 
optic  nerves,  causing  blindness.  The 
foramina  and  canals  through  which  the 
cranial  nerves  pass  are  narrowed  and 
symptoms  of  pressure  result  (loss  of 
sense  of  smell,  trigeminal  neuralgia, 
etc.).  Frequently  suppurative  dacro- 
cystitis  and  erysipelas  of  the  face  and 
head  precede  the  development  of  the 
disease,  but  it  is  not  probable  that 
they  have  any  etiological  relation  to  it. 
Treatment  has  no  effect  upon  the  course 

of  the  disease.     Even  resection  of  the  bones  first  involved  does  not  delay 
its  progress. 

Acromegaly  was  first  described  by  P.  Marie  in  1886.  In  this  disease 
there  is  not  only  a  hypertrophy  of  the  bones  of  the  distal  parts  of  the 
extremities,  of  the  skull  and  face  due  to  a  proliferation  of  the  peri- 
osteum, but  also  a  thickening  of  the  soft  parts.  In  the  head  the  hyper- 
trophy affects  most  commonly  the  lower  jaw,  nose,  lower  lip,  and  tongue. 
In  some  instances  the  penis  or  clitoris  is  hypertrophied.  [In  a  number 
of  cases,  the  external  genitalia  have  been  smaller  than  normal.]  The 
disease  begins  in  young  or  middle-aged  people  and  produces  changes 
in  the  physiognomy  and  in  the  shape  of  the  feet  and  hands  which  are 
very  characteristic.  The  disease  is  supposed  to  be  due  to  diseases  of 
the  hypophysis  (tumors,  hypertrophy,  cysts,  and  sclerosis).  ["  Tam- 
burini's  suggestion  that  acromegaly  is  dependent  upon  excessive  func- 
tion of  the  hypophysis  is  highly  important.  As  yet  no  cases  of  undoubted 
acromegaly  have  been  reported  in  which  changes  in  the  gland  were 
absent  upon  both  gross  and  microscopic  examinations,  and  in  those  in- 
stances where  necrosis  and  softening  (probably  post  mortem),  sclerosis, 
colloid  degeneration,  etc.,  have  been  found,  no  mention  is  made  of  the 
relation  between  chromophile  and  chromophobe  elements.  Experimental 
removal  of  this  gland,  its  destruction  by  neoplasm,  infectious  granu- 
lomata,-  and  aneurysm  do  not  produce  tlie  disease,  so  that  it  seems 
proper  to  assume  that  acromegaly  is  not  dependent  upon  an  abolished 
or  lessened  function  of  the  hypophysis." — Lewis,  The  Johns  Hopkins 


738       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS  AND   TUMORS 

Hospital  Bulletin,  Vol.  XVI,  May,  1905,  p.  164.]  Paraesthesias  and 
slight  pain  in  the  extremities,  loss  of  the  finer  sensations  in  the  hands 
and  feet,  and  loss  or  decrease  in  sexual  desire  are  common.  The  hands 
and  feet  gradually  become  clumsy  and  pawlike  or  spadelike,  as  the 
bones  become  thickened  by  the  formation  of  new  bone,  which  is  most 
pronounced  near  the  ends.  The  bones  of  the  forearms  and  legs  also 
become  considerably  thickened.  The  changes  in  the  face  are  most 
striking,  as  the  lower  jaw  enlarges  and  projects  beyond  the  upper, 
as  the  lips,  eyelids,  nose,  ears,  tongue,  and  cheeks  become  thickened, 
often  causing  folds  in  the  skin.  Gradually  kyphosis  develops,  while 
the  bones  of  the  trunk  widen.  Cachexia  gradually  develops,  the 
heart  and  large  vessels  become  diseased,  and  the  disease  terminates 
fatally  after  a  number  of  years.  Acromegaly  is  especially  frequent 
in  giants.  The  only  relation  between  gigantism  and  acromegaly  is 
that  the  former  seems  to  predispose  to  the  development  of  the  latter. 
According  to  Arnold  there  is  no  increase  in  the  length  of  bones  in 
acromegaly. 

Acromegaly  cannot  be  mistaken  for  leontiasis  ossea  if  a  careful  ex- 
amiiuition  is  made,  as  in  the  latter  the  fingers  and  toes  are  not  involved. 
Usually  arthritis  deformans  can  be  easily  differentiated,  as  the  changes 
in  acromegaly,  although  they  involve  the  ends  of  the  bones,  are  extra- 
articular {vide  Schuchardt). 

Similar  changes,  involving  especially  the  terminal  phalanges  of  the 
fingers  and  toes,  and  the  epiphyses  of  long,  hollow  bones,  occur  in  young 
children  suffering  from  chronic  diseases  of  the  heart  and  lungs  (Bam- 
berger) .  The  enlargement  is  due  to  the  proliferation  of  the  periosteum. 
P.  ]\Iarie  has  grouped  these  pathological  manifestations  and  described  a 
distinct  clinical  entity  which  he  calls  osteoarihropathie  hypertrophiante 
pneumique. 

LiTKRATURK. — Bardenhcuer  und  Lossen.  Leontiasis  ossea  Kolner  Festschrift, 
1904,  p.  154. — Mauclaire.  Maladies  non  traumatiques  des  os.  Traite  de  chir.,  le 
Dentvi  ct  Delbet.  Paris,  1896.  T.  II,  p.  723.— Schuchardt.  Die  Krankheiten  der 
Knochen  und  Gelenke.     Deutsche  Chir.,  1899,  pp.  150,  225. 


(d)  RICKETS 

Definition. — Kickets  from  the  Greek  paxis,  meaning  spine)  is  a 
genci-nl  disease  of  malnutrition  occurring  in  children  and  manifesting 
itself  iiifiiiily  in  lesions  connected  with  the  bones.  It  usually  connnences 
williiii  I  he  (iisl  lliree  years  of  life,  but  sometimes  appenrs  later  (Rose 
Mild  ("nrlcss,  "  IMninial  of  Surgery,"  p.  5!)7).  The  disease  was  first 
accurately  described  by  Glisson,  an  Englishiiuiii,  and  tlierefore  the  dis- 
ease is  often  referred  to  in  Germany  as  the  English  disease. 


DISEASES  OP  BONE  739 

Pathological  Changes. — Rickets  is  characterized  by  changes  in  nor- 
mal bou(^  (U'velopiiu'iit  consisting-  of  an  excessive  foi-iuation  of  osteoid 
tissue  which  is  prepared  for  bone  formation,  a  diminished  deposit  of 
lime  salts  in  this  tissue,  and  an  increased  resorption  of  newly  formed 
l)()ne.  The  most  striking  symptoms  of  the  disease  are  enlargements  of 
tlie  epiphyses  due  to  broadening  of  the  epiphyseal  cartilages,  and  the 
development  of  deformities,  the  result  of  softening  and  ftexihility  of 
the  bones.  The  calcium  content  of  the  bones  is  reduced  more  than 
one  half. 

Osteoid  tissue  develops  upon  the  surface  of  the  bone  and  in  the 
medulla,  especial Ij^  upon  the  metaphyseal  side  of  the  epiphyseal  car- 
tilages, forming  vascular,  spongy,  soft,  grayish  red  masses  of  tissue. 
The  periosteal  deposits  of  this  osteoid  tissue  are  localized  and  may  be 
removed  with  the  thickened  periosteum.  The  myelogenous  deposits  in 
severe  cases  are  not  localized,  but  are  distributed  throughout  the  entire 
metaphysis.  Normal  endochondral  bone  formation  is  greatly  altered. 
The  epiphyseal  cartilages  are  greatly  widened,  and  there  is  a  consid- 
erable increase  in  the  number  of  columns  of  proliferating  cartilage 
cells.  Normally  the  epiphyseal  cartilage  is  a  well-defined,  bluish  white 
or  white  line,  cartilage  and  bone  being  sharply  differentiated  from  each 
other.  In  rickets  the  epiphyseal  cartilage  becomes  broadened  and  ir- 
regular, its  sharp  outlines  are  lost  and  medullary  spaces  and  osteoid 
tissue  extend  into  the  cartilage,  and  the  delicate  white  streak  indica- 
tive of  primary  calcification  disappears.  The  epiphyseal  cartilages 
appear  broad,  and  are  provided  with  irregular  proce&ses  and  outgrowths 
Avhich  may  become  separated  to  form  islands  of  cartilage  within  the 
osteoid  tissue.  Bony  trabecula;  and  calcified  cartilage  are  also  found 
within  the  latter.  [The  development  of  multiple  osteomata  or  chon- 
dromata  is  supposed  to  be  secondary  to  rickets,  the  displaced  island  of 
cartilage  forming  the  nuclei  for  these  benign  tumors.] 

There  is  also  an  increased  lacunar  resorption  of  the  newl}^  formed 
bone,  and  in  this  way  the  medullary  spaces  and  the  Haversian  canals 
become  enlarged,  an  osteoporosis  developing.  Areas  may  be  found  in 
flat  bones  in  which  the  normal  bone  is  entirelj''  replaced  by  osteoid  tissue. 
Decalcification  may  be  as  marked  as  in  osteomalacia  (von  Reckling- 
hausen). 

Calcification  of  this  osteoid  tissue  does  not  occur  at  all  or  inter- 
mittently, depending  altogether  upon  whether  the  disease  progresses 
without  abatement  or  improves.  As  the  patient  is  recovering  from  the 
disease,  the  osteoid  tissue  becomes  transformed  into  hard  sclerotic  bone, 
which  may  completely  occlude  the  medullary  cavity.  The  deformities 
which  may  have  developed  then  become  permanent.  Slight  bending  of 
the  bones  may  be  corrected  during  subsequent  growth. 


740       SURGICAL   DISEASES,   EXCLUDING  INFECTIONS   AND   TUMORS 


Etiology. — The  cause  of  these  alterations  in  the  development  of  bone 
is  unknown,  notwithstanding  the  number  of  investigations  that  have 
been  made.    One  view  held  by  Pommer,  Heubner,  and  Zweifel  is  that  the 

deficient  calcification  of  the  osteoid  tissue 
is  the  result  of  nutritional  disturbances. 
Kassowitz  ascribes  the  changes  to  a  chron- 
ic inflammatory  hypera'mia,  the  cause  of 
which  is  unknown.  A  number  of  impor- 
tant objections  have  been  raised  against 
each  of  these  views.  In  spite  of  this,  one 
cannot  help  thinking  that  the  changes  are 
due  to  the  action  of  some  toxic  material 
which  accumulates  in  the  blood,  as  the 
result  of  the  loss  of  function  of  some  one 
of  the  ductless  glands  (according  to  Stoltz- 
ner,  possibly  the  suprarenal)  and  acts 
upon  the  bone,  especially  upon  the  articu- 
lar ends  where  there  is  a  physiological 
hyperasmia.  It  can  be  definitely  stated, 
in  spite  of  the  fact  that  the  breast-fed 
children  of  the  well-to-do  classes  are  not 
spared  by  the  disease,  that  insufficient  or 
improper  food  is  an  important  etiological 
factor,  and  that  poor  hygienic  conditions, 
the  want  of  air  and  light,  uncleanliness, 
and  intestinal  catarrh  predispose  to  it. 

The  disease  develops  most  commonly 
during  the  second  year  of  life ;  very  rarely 
after  the  fifth  or  sixth.  The  cases  ob- 
served during  the  fifth  and  sixth  years  are 
usually  merely  exacerbations  of  mild  eases 
which  have  persisted  for  some  time.  It  is  a  disputed  question  whether 
the  changes  observed  in  rickets  are  ever  congenital.  The  changes  ob- 
served in  the  so-called  fatal  rickets  (p.  783)  have  no  relation  whatever 
to  the  changes  found  in  the  disease  under  consideration.  In  the  so-called 
liitc  i-ickets  (rachitis  tarda)  developing  at  puberty,  the  bones  become 
soft  and  yielding,  and  deformities  such  as  curvature  of  the  spine  (ha- 
bitual scoliosis)  and  of  the  ends  of  the  long  bones  (genu  valgum  and 
vaiuin  adolescentium,  coxa  vara)  develop,  the  softened  bones  yielding 
niidrr  the  weight  of  the  superimposed  parts.  The  pathological  changes 
ill  lalf  rickets  differ  from  those  occurring  in  earlier  life,  being  limited 
to  that  part  of  the  metaphysis,  poor  in  lime  salts,  immediately  adjacent 
to  tli(r  hyp«'itroj)hied  epiphyseal  cartilage  (Fig.  279). 


Fig.      278.  —  Coronal     Section 

THROUGH  THE  LoWER  EnD  OF 
THE    J^EMUR    OF    A    ChILD   TwO 

AND  A  Half  Years  of  Age 
Suffering  avith  Rickets. 
(After  Kaufmann.)  a,  Lower 
epiphysis,  normal  cartilage;  h, 
mottled,  bluish  red,  swollen, 
soft  zone  of  proliferating  car- 
tilage; c,  zone  in  which  the 
vessels  and  medullary  spaces 
with  osteoid  tissue  have  pene- 
trated the  soft  cartilage;  d, 
osteoid  tissue;  e,  dilated  me- 
dullary cavity  with  but  little 
spongy  bone;  /,  thinned  com- 
pact bone  covered  by  a  layer 
of  osteoid  tissue. 


DISEASES   OF    BONE 


741 


The  severest  and  most  resistant  cases  occur  chiefly  in  the  children 
of  the  poor  classes  living  in  cities,  among  whom  the  disease  is  also  most 
connnon.  The  disease  is  rare  among  the  children  of  the  middle  classes, 
and  if  it  does  develop  it  is  mild  and  is  easily  cured. 

Onset  and  Changes  in  Bones. — It  is  not  possible  to  state  definitely 
when  the  disease  begins,  as  it  has  an  insidious  onset.  Frequent  and  2)>'0- 
fiise  sweating,  tenderness  of  the  hones,  ancemia,  and  myasthenia  are 
recognized  as  prodromata  by  physicians  experienced  in  children's  dis- 
eases.    Suspicion  may  be  aroused  when  the  child  first  attempts  to  walk. 

The  course  of  the  disease  is  always  chronic.  As  a  rule  the  earlier 
the  disease  develops  the  more  rapid  the  course.  In  the  beginning  the 
rapid  involvement  of  the  different  bones  is  often  quite  striking.  From 
time  to  time  the  symptoms  subside,  but 
exacerbations  are  frequent,  especially  dur- 
ing the  winter  months,  when  the  hygienic 
conditions  are  apt  to  be  poor. 

The  osteal  symptoms  vary  a  great  deal, 
and  only  in  the  severest  cases  are  they 
eciually  prominent  in  all  the  bones.  In 
these  cases  growth  is  retarded  (rachitic 
dwarf),  the  epiphyses  become  enlarged 
and  expanded,  the  flat  bones  become 
thickened,  sometimes  atrophied,  and  de- 
formities of  the  long,  hollow  bones,  caused 
by  muscular  action  or  by  the  weight  of 
the  superimposed  parts,  develop  and  frac- 
tures may  occur.  In  the  milder  cases 
growth  is  scarcely  interfered  with,  there 
is  less  tendency  to  bending  of  the  bones, 
deformities  are  wanting,  or  if  they  do 
develop  they  are  limited  to  the  ends  of 
the  bones  (e.  g.,  genu  valgum),  and  the 
enlargement  of  the  epiphyses  is  not 
marked. 

Changes  in  the  Skull  Bones. — In  the 
skull,  especially  in  the  occipital  regions, 
the  bones  may  become  soft  and  yielding, 
and  as  a  result  of  the  loss  of  bone,  some 
portions  may  become  membranous  again 
(cranio-tabes).  The  fontnnellcs  are  wide 
long  time,  until  the  third  or  fourth  year 
forehead  appears  stpuire  in  shape,  while  the  parietal  and  frontal  emi- 
nences are  enlarged  by  deposits  of  osteoid  tissue  beneath  the  periosteum. 


Fig.  279. — Genu  Valgum  Adoles- 
CENTiuM.  (From  a  patient  sev- 
enteen years  of  age.) 

and  may  remain   open  for  a 
The  head  is  larue,  and  the 


742       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 

Sometimes  the  changes  in  the  skull  are  associated  with  hydrocephalus. 
The  liard  palate  becomes  high  and  arched,  the  alveolar  border  of  the 
maxilla  projecting  forward  like  a  beak,  while  the  symphysis  of  the 
mandible  becomes  flattened.  The  teeth  do  not  erupt  until  late,  are 
stunted,  defective  in  enamel,  and  decay  early. 

CJtcntges  in  the  TJiorax. — In  the  thorax  there  develops  at  the  junction 
of  the  ribs  with  the  cartilages  a  row  of  round  nodules  (rachitic  rosary) 
which  may  often  be  seen  through  the  skin.  If  there  is  any  obstruction 
to  the  entrance  of  the  air  (tracheitis  or  bronchitis)  the  atmospheric 
pressure  may  cause  the  softened  bones  and  cartilages  to  sink  in,  and 
as  a  result  the  sternum  is  pushed  forward,  producing  a  typical  deform- 
ity known  as  the  "  chicken  breast  "  or  pectus  carinatum.  The  natural 
ctirves  in  the  clavicle  may  also  be  accentuated.  A  transverse  groove 
(Harrison's),  corresponding  in  position  to  the  attachment  of  the  dia- 
phragm, often  develops  across  the  lower  part  of  the  chest.  It  is  pro- 
duced by  the  traction  of  this  muscle  upon  the  softened  ribs  and  carti- 
lages. The  projection  or  flaring  of  the  ribs  below  this  line  is  caused 
by  the  enlargement  of  the  abdominal  viscera. 

A  kyphosis  develops  in  the  lower  dorsal  and  lumbar  regions,  espe- 
cially in  children  who  are  carried  a  great  deal.  [This  kyphosis,  which 
extends  over  a  number  of  vertebrte,  is  never  angular  as  in  tuberculosis.] 
Scoliosis  is  rare. 

Changes  in  the  Pelvis. — The  changes  in  the  pelvis  may  be  marked, 
but  are  of  interest  chiefly  to  the  obstetrician,  as  they  may  interfere  with 
childbirth.  The  pelvis  becomes  flattened  from  before  backward,  and 
the  cavity  becomes  contracted  as  the  promontory  of  the  sacrum  projects 
forward  and  downward  and  the  bone  surrounding  the  acetabulum  is 
forced  inward  and  the  symphysis  forward. 

Changes  in  the  Bones  of  the  Extremities. — The  changes  in  the  bones 
of  the  extremities  are  the  most  striking.  Tender  thickenings  may  be 
palpated  upon  the  ends  of  the  long,  hollow  bones  (especially  upon  the 
carpal  ends  of  the  radius  and  ulna  and  upon  the  malleoli)  which  are 
not  covered  by  thick  soft  tissues.  The  entire  or  part  of  the  diaphysis 
becomes  bowed.  The  bowing  is  most  common  in  the  femur  and  tibia, 
being  most  commonly  forward  and  outwartl.  The  lower  third  of  the 
tibia  bows  forward,  and  may  become  so  flattened  from  side  to  side  that 
it  resembles  a  saber  sheath.  The  angular  deformities  developing  at  the 
metaphysis  or  in  the  diaphysis  are  secondary  to  green-stick  fractures. 
If  the  direction  of  the  articular  ends  of  the  bones  is  changed  by  a 
bending  of  the  softened  metaphysis,  typical  deformities,  such  as  genu 
valgnni,  varum,  recnrvatuni,  rachitic  flat-foot,  and  coxa  vara,  develop, 
tlic  diaphysis  I'cmaining  normal  or  becoming  bowed.  [The  bowing  of 
the  diaj)hysis  in  these  cases  is  usually  secondary  and  compensatory.] 


DISEASES  OF   BONE 


743 


Similar  deformities   in   tlie   bones  of  the   iii)p('r   extremity   oeetii"   only 
in  children  who  have  been  accnstomed  to  creep  about  on  all   fours. 

Sclerosis  of  Bones  When  Disease 
Improves.  —  When  the  acute  stages 
of  the  disease  have  passed  and  im- 
provement begins,  sclerosis  of  the 
bones  occurs.  This  process  of  hard- 
ening may  be  frequently  interrupted 
by  exacerbations  of  the  disease.  As 
the  sclerosis  progresses  the  epiphys- 
eal enlargements  become  smaller,  the 
fontanelles  close,  growth  becomes  more 
rapid,  and  the  general  condition  im- 
proves. 

Spontaneous     Correction     of     De- 
formities.— The   deformities   gradually 
improve,    rarely    remaining    as    great 
as  they  were  at  the  time  they  devel-, 
oped.     It  has  been   observed 
for  a  number   of  years   that 
the   improvement   is  gradual, 
and  that,   as  a   rule,  the   de- 
formities   have    become    less 
or    have    completely    disappeared    at 
the  age  of  puberty.     The  more  rapid 
the  growth,    the    more    rapid   the   im- 
provement in  the  deformities  is.    Usu- 
ally from   two   to   four  years  are   re- 
quired   for    the    correction.      Clinical 
observaticms    made    by    Schlange    and 
Veit   in   von    Bergniann's   clinic    have 
shown  that  the  deformities  in  rachitic 
children   whose   growth   has   not   been 
stunted    or    retarded    subside    sponta- 
neously and  completely  in  the  sixth  or 
seventh  year.     According   to   Kamp's 
investigations,  this  occurs  in  seventy- 
five  per  cent  of  the  cases.     In   cases 
in  which  the  growth  has  been  stunted, 
some  improvement  may  occur,  but  con- 
siderable   deformity    remains.      After 
the    age    limit    above    mentioned    has 
been  reached,   an   increase  in   the   de- 


marked 


Fig.  280. — Rickkts.  The  changes  are 
most  pronounced  in  the  legs  wliich 
are  considerably  shortened.  The 
thiglis  are  rotated  outward  because 
of  the  distortion  of  the  neck  of  the 
femur.  The  shaft  of  each  femur  is 
bent  forward  and  outward.  The 
tibitD  at  the  position  of  the  ufjper 
metaphyses  are  bent  inward,  pro- 
ducing genua  valga.  The  deformit  ies 
at  the  lower  metaphyses,  resulting 
from  a  bending  forward,  are  less  pro- 
nounced. Other  changes  associated 
with  rickets,  such  as  double  flat-foot, 
some  thickening  of  the  lower  epiph- 
yses of  the  radius  and  ulna,  widen- 
ing of  the  costal  arch,  and  the  rick- 
ety rosary,  are  also  present. 


744       SURGICAL   DISEASES,   EXCLUDING   INFECTIONS   AND  TUMORS 

formities  cannot  be  determined,  even  when  the  disease  persists,  but 
the  bones  remain  shortened,  are  capable  of  but  little  growth,  and  the 
patient  remains  a  dwarf.  Some  bowing  of  the  diaphysis  and  enlarge- 
ment of  the  epiphyseal  ends  of  the  bones  may  remain  permanently  in 
even  the  most  favorable  cases,  and  often  are  indicative  of  a  previous 
rickets. 

Changes  in  the  Bones  Shown  hy  X-Bays. — Recently  X-ray  pictures 
of  the  diseased  long  bones  have  shown  a  number  of  other  changes  be- 
sides the  deformities.  The  epiphyseal  cartilages  are  broad,  irregular, 
and  fi])rillated,  the  cortical  layer  of  bone  is  thin,  and  in  it  are  indis- 
tinct, localized  shadows  due  to  the  absence  of  lime  salts.  If  heal- 
ing has  occurred,  the  epiphyseal  lines  become  almost  as  narrow  as  in 
healthy  bone,  and  delicate,  parallel  streaks  (calcification  lamella^)  run- 
ning out  from  the  epiphyseal  cartilage  appear  in  the  metaphysis.  A 
thickening  is  found  in  the  cortex  which  is  most  marked  upon  the 
concave  side  of  the  deformity,  as  the  greatest  weight  is  placed  upon 
this  side. 

General  Symptoms. — The  general  symptoms  may  be  mild  or  severe, 
and  vary  from. a  slight  nmscular  weakness  and  atrophy  to  a  decided 
anaemia  and  emaciation.  Intestinal  disturbances  (meteorism  with  diar- 
rhcBa  or  obstipation),  a  tendency  to  catarrhal  inflammations  of  the  lungs 
resulting  from  narrowing  of  the  thorax,  swelling  of  the  lymph  nodes, 
sweating,  eczema,  and  finally,  nervous  disturbances,  such  as  unrest,  con- 
vulsions, and  laryngeal  spasm,  are  frequent. 

The  principal  dangers  which  accompany  the  severer  forms  of  rickets 
are  weakness  and  the  loss  of  resistance  to  infections.  Catarrhal  inflam- 
mations of  the  lungs,  diarrhoea,  and  infectious  diseases  may  run  rapid 
and  fatal  courses.  Complications  such  as  tuberculosis  and  syphilis  are 
to  be  especially  feared.  Many  rachitic  children  die  of  some  of  the 
acute  infectious  diseases  of  childhood.  The  disease  tends  to  inidergo 
spontaneous  cure,  and  even  the  deformities  which  have  developed  in 
earlier  times  may  be  corrected  or  improved  as  the  patient  grows.  Some 
of  these  deformities  remain,  however,  and  may  give  rise  to  serious  com- 
plications in  later  life  (e.  g.,  rachitic  pelvis  in  childbirth). 

Diagnosis. — The  diagnosis  is  usually  not  difficult,  even  when  the 
symptoms  are  not  pronounced.  The  X-ray  findings,  when  positive,  are 
so  cliaractei'istic  as  to  leave  no  doubt  as  to  the  diagnosis. 

Treatment:  Medicinal  and  Surgical. — The  treatment  in  the  beginning 
belongs  to  internal  medicine.  In  the  treatment,  as  M'ell  as  in  the  proph- 
ylaxis, special  emphasis  should  be  laid  upon  the  improvement  of  the 
hygienic  conditions  and  the  nutrition  of  the  patient.  Phosphorus  is 
supposed  by  many  to  have  a  favorable  influence  upon  the  diseases. 
Kassowilz,    basing    his    conclusions   upon   animal    experiments,    believes 


DISEASES  OF   BONE  745 

that  phosphorns,  which  was  advised  by  Wogner  in  the  trcatnioiit  of  this 
disease,  has  no  action  at  all. 

Surj^'cry  has  to  do  with  the  reduction  and  dressin<i'  of  fractures  Avhich 
occur  during  the  disease  and  with  the  correction  of  deformities.     The 


Fir..  281. — X-Ray  Picti:ke  of  I)KK(iu.MP:n,  RAcimie  Boxes  of  the  Leg  (IIealixc.  has 
Occurred).  The  epiphyseal  cartilages  are  aliiio.st  normal.  The  cortex  is  especially 
thickened  iipon  the  concave  side  of  the  tibia. 

deformities  may  be  corrected  (at  one  or  more  sittings)  hy  osteoclasis, 
nsing  manual  force  or  special  osteocLasts,  or  by  linear  osteotomy  if  the 
deformity  is  not  great,  by  cuneiform  osteotomy  if  it  is.  These  pro- 
cedures are  nsnally  employed  after  the  sixtli  year  of  life,  before  tliis 
time  only  when  the  deformities  are  excessive  or  when  the  sclerosis  de- 
velops early  and  is  marked.  If  the  bones  are  hai'd  and  sclerotic,  osteot- 
omy as  a  rule  is  to  he  preferred  to  osteoclasis.  In  recent  cases  any  of 
these  ])rocednres  are  to  be  avoided  as  the  subsecpient  innnobilization  in 
48 


746       SURGICAL   DISEASES,   EXCLUDING  INFECTIONS   AND   TUMORS 

plaster-of-Paris  dressings,  wliich  is  reciuired,  increases  the  mnscular 
atropliy,  and  besides,  most  of  the  deformities  undergo  spontaneous  correc- 
tion. Orthopedic  apparatus,  which  by  traction  or  pressure  prevents  ))ow- 
ing  of  the  bones,  is  to  be  dispensed  with  for  the  same  reasons.  Curvature 
of  the  spine  and  rachitic  flat-foot  demand  early  support  (piaster-of-Paris 
jackets  and  flat-foot  arches),  as  they  usually  are  permanent. 

The  child  should  be  allowed  neither  to  run  about  nor  be  carried 
as  long  as  the  bones  remain  soft.  As  the  bones  become  hard  the  child 
should  be  allowed  to  play,  when  possible,  in  the  open  air.  In  this  way 
the  development  of  muscles  is  favored,  growth  becomes  more  rapid, 
and  the  general  condition  improves. 

Barlow's  Disease. — A  disease  known  as  inf(uitile  scurvy  (Barlow's  or 
Moller's  disease  and  ha^morrhagic  rickets),  which  involves  bone,  is  some- 
times associated  with  rickets  and  at  other  times  occurs  as  an  independent 
affection.  It  is  regarded  by  some  as  a  hannorrhagic  form  of  rickets,  by 
others  as  a  peculiar  form  of  scurvy.  Nothing  is  known  concerning  its 
cause  and  exact  nature. 

It  begins  with  severe  pain  in  the  bones,  which  is  soon  followed  by 
swelling  due  to  subperiosteal  ha:nnorrhages.  These  heemorrhages  are  most 
common  in  the  lower  end  of  the  femur  and  in  the  upper  end  of  the  tibia ; 
rare  in  tiie  bones  of  the  upper  extremities  and  the  bones  of  the  trunk. 
Exophthalmos  may  develop,  being  caused  by  retrobulbar  hiematomas. 
Ha'morrhages  from  the  gums  and  skin  and  ha^maturia  complete  the  pic- 
ture of  the  hivmorrhagic  diathesis.  Osteoporosis  follows  the  imperfect 
ossificati(m  and  progressive  resorption  of  bone,  and  pathological  fractures 
and  separation  of  the  epiphyses  are  frequent.  Ha'morrhages  may  occur 
in  the  altered,  gelatinous,  and  fibrous  bone  marrow  poor  in  cells. 

The  disease  is  most  common  in  children  from  one  half  to  one  year 
of  age  who  have  been  poorly  nourished  or  have  been  fed  with  poor 
artificial  foods.  Severe  anaemia  and  great  weakness  develop  rapidly, 
and  the  disease  ends  fatally  after  some  weeks  if  the  food  is  not  changed 
and  i)ro[)erly  modified  cow's  milk  given.  With  proper  diet  the  general 
condition  gradually  improves  until  recovery  is  complete. 

There  is  little  of  surgical  interest  in  this  disease  except  the  treat- 
ment of  the  fractures  which  occur,  and  making  the  diagnosis  between 
it  and  inflammatory  separation  of  the  epiphysis  and  bone  tumors.  The 
development  of  nuiltiple  osteal  swellings,  of  hannorrhages  into  the  skin 
and  fi-om  the  nnicous  membranes  enables  one  to  make  a  positive  diagnosis. 

LiTKUATUiiE. — Ilauser.  Grundriss  der  Kinderheilkunde.  Wiesbaden,  190L — 
Hebmr.  Lchrbuch  der  Kinderkrankheiten.  Leii)zif!;,  1903. — Neumann.  Sauglings- 
Hkorbut  (Rarlowsohc  Krankhoit).  Deutsche  Klinik,  Bd.  7,  1904,  p.  Ml.—Schxichardt. 
Die  Krankheitcn  (k-r  KncK-hcn  uiid  Gelenke.  Deutsche  Chrr.,  1899. — Stoltzner.  Path- 
ologic   wild    'i'lifniiiic    der    Rachitis.     Berlin,     1904. — Zappert.     Rachitis.     Deutsche 


DISEASES   OF    BONE  747 

Klinik,  Bd.  7,  1904,  p.  427. — Zesas.  Altes  uiul  Neues  iiber  Rhachitis.  Zentralbl.  f. 
Grenzgebiete.  Sammelref.,  1906,  p.  321. — Zicgler.  Ueber  Osteotabos  infantum  und 
Rachitis.  Zentralbl.  f.  Pathol.,  1901,  p.  865. — Zweifel.  Aetiologie,  Prophylaxis  und 
Therapie  der  Rhachitis.     Leipzig,  1900. 

(e)  OSTEOMALACIA 

Definition. — Osteomalacia,  like  rickets,  is  a  disease  in  which  there  is 
a  general  involvement  of  the  bones.  Osteomalacia,  however,  is  charac- 
terized by  regressive  changes  occurring  in  fully  developed,  strong  bones 
of  adults,  resulting  in  softening,  while  in  rickets  the  pathological  changes 
involve  the  young,  developing  bone  which,  as  a  result,  remains  soft  and 
does  not  become  hard  until  later  in  life. 

Etiology. — This  rare  disease  occurs  only  in  adults,  most  frequently  of 
the  female  sex  (only  eight  per  cent  of  the  cases  reported  were  in  males), 
who  live  among  poor  hygienic  surroundings  and  have  passed  through  a 
number  of  pregnancies.  Its  common  occurrence  in  certain  regions 
(South  Germany,  Italy,  Switzerland)  suggests  some  endemic  influence; 
the  marked  hypera^mia  of  the  medulla  in  the  beginning  of  the  diseases 
some  inflammatory  or  vasomotor  disturbance.  Nothing  definite  is 
known,  however,  concerning  the  cause  of  the  disease. 

Pathology. — The  pathological  changes  consist  principally  of  decal- 
cification (halisteresis).  The  changes  begin  upon  the  trabecular  of  the 
spongy  bone  and  about  the  Haversian  canals.  Gradually  the  bones 
soften  as  the  ground  substance  becomes  decalcified  and  disappears.  In 
the  beginning  of  the  disease  haemorrhages  occur  into  the  marrow,  and 
later  accunuilations  of  pigment,  the  remains  of  the  hfemorrhages,  are 
found.  The  marrow  becomes  gelatinous  and  liquefied  to  form  cysts. 
The  new  bone  which  develops  in  some  areas,  and  which  after  fractures 
may  lead  to  excessive  callus  formation,  consi-sts  almost  entirely  of  oste- 
oid tissue,  as  calcification  does  not  occur. 

As  a  result  of  these  changes  the  bones  become  fragile  and  so  soft 
that  they  bend  like  india  rubber  when  subjected  to  pressure  or  acted 
upon  by  the  muscles.  They  become  so  soft  that  they  may  be  easily 
cut  with  a  knife  or  compressed  between  the  hands.  In  the  severest 
cases  the  shaft  of  the  long  bones  may  become  as  thin  as  paper  or  may 
completely  disappear,  leaving  only  the  periosteum,  which  then  resembles 
an  intestinal  loop,  filled  M'itli  pathological  masses  of  bone  marrow. 

Clinical  Course. — Slowly  this  frightful  disease  pursues  its  course, 
often  interrnptcnl  by  periods  in  which  the  changes  remain  stationary 
and  improvement  occurs.  Occasionally  the  bones  become  sclerotic  .-md 
the  newly  formed  bone  becomes  calcified,  and  recovery  occurs.  A  I'tcr 
years  of  sufl'ering,  death  from  cachexia,  pulmonary'  or  intestinal  dis- 
eases or  from  some  terminal  infection  occurs. 


748       SURGICAL   DISEASES,   EXCLUDING  INFECTIONS   AND  TUMORS 

The  puerperal  form  begins  during  pregnancy,  sometimes  during  the 
puerperium,  with  severe  rheumatic  pains  in  the  lower  part  of  the  trunk. 
Gradually  softening  of  the  bones,  which  usually  begins  in  those  of 
the  pelvis,  is  indicated  by  limitation  of  motion  at  the  hip  joint,  giving 
rise  to  a  peculiar  waddling  gait,  and  by  a  distinct  decrease  in  the  body 
length,  the  trochanters  being  forced  upward  as  the  necks  of  the  femora 
become  soft  and  yielding,  the  acetabula  being  pressed  inward  and  back- 
ward and  the  promontory  of  the  sacrum  sinking  downward  and  for- 
ward. The  pehns  then  becomes  of  a  triradiate  or  clover-leaf  shape. 
Often  the  disease  is  limited  to  the  bones  primarily  involved,  and  in  mild 
cases  they  may  become  sclerotic,  and  recovery  occurs.  But  the  reverse 
may  happen  if  pregnancy  occurs,  the  disease  extending  rapidly.  If  the 
softening  extends  to  the  vertebrae,  ribs,  and  sternum,  the  chest  wall 
becomes  flattened  and  deformed  and  different  varieties  of  spinal  curva- 
ture will  develop.  The  bones  of  the  extremities  may  then  become  tender 
and  soften.  When  the  softening  is  complete  the  bones  may  be  bent  in 
almost  any  direction,  while  active  motions  become  impossible.  Only  the 
bones  of  the  skull  and  face  are  spared  by  these  grosser  changes.  The 
patient,  completely  bedridden,  dies  in  a  few  years  from  exhaustion  or 
some  disease  of  the  lungs.  The  deformity  of  the  chest  predisposes  to 
diseases  of  the  lungs. 

The  non-puerperal  cases,  which  almost  always  pursue  a  rapid  course, 
usually  begin  in  the  vertebra?.  They  may  begin  with  repeated  patho- 
logif-al  fractures   (Riedel). 

Diagnosis. — The  diagnosis  is  possible  only  when  the  symptoms  are 
pronounced.  In  the  earlier  stages,  when  the  sj-mptoms  point  to  osteo- 
inalar-ia.  X-rny  pictures  should  be  taken. 

Treatment. — Phosphorus  (combined  with  cod-liver  oil)  should  be 
administered  for  a  long  time,  as  hardening  of  bone,  which  in  the  mild 
puerperal  cases  may  occur  spontaneously  and  end  in  recover^',  is  fa- 
vored by  this  drug.  The  general  strength  of  the  patient  should  be 
improved  by  good  nutritious  diet  and  hygienic  conditions.  The  de- 
formed extremities  should  be  maintained  in  proper  position,  if  neces- 
sary, by  extension  dressings. 

1  r  pregnancy  occurs,  the  induction  of  premature  labor  is  advised  by 
some,  not  only  for  the  purpose  of  checking  the  disease,  but  also  for  the 
I)Mr{)ose  of  obvinting  such  operations  as  craniotomy,  cephalotripsy,  and 
Ca*sarean  section.  Tlio  removal  of  the  uterus  and  its  appendages,  ac- 
cording to  I'oiTo,  or  of  the  ovaries  alone,  according  to  Fehling,  has 
been   followed   in  innny  cases  by  rapid  improvement  and  recovery. 

Paget's  Disease  of  Bone. — Paget 's  disease  of -bone,  or  osteitis  de- 
fnrmniis  (osteomalacia  cin-onica  deformans  hypertrophica,  osteomyelitis 
librosa),  is  closely  related  to  osteomalacia.    It  occurs  most  frequently  in 


DISEASES  OF   BONE  749 

adults  of  ail  advanced  age,  and  affects  nsnally  the  shafts  of  the  bones 
of  the  lower  extremity  (frequently  the  tibia  on  one  side),  the  clavicles, 
the  calvarivuu,  the  ribs,  and  the  vertel)ra'.  Deformities,  accom[)anied 
by  considerable  painful  thickening  of  the  bones,  gradually  develop. 
There  is  a  decrease  in  body  length,  as  the  vertebra;  sink  together  and 
the  bones  of  the  lower  extremities  bow.  The  arms  (which  remain  nor- 
mal) appear  long,  and  the  general  appearance  of  the  patient,  with  the 
clumsy  gait,  the  drooping  shoulders,  the  flexed  head,  the  prominent 
abdomen,  and  with  the  lower  extremities  slightly  bowed  and  rotated 
outward,  remind  one  of  a  large  anthropoid  ape  (vide  Schuchardt). 
Death,  which  follows  after  years  of  suffering,  is  due  most  frequently 
to  some  disease  of  the  lungs,  the  development  of  which  is  favored  by 
the  narrowing  of  the  thorax.  It  is  also  relatively  frequently  caused 
by  sarcomas  which  develop  from  one  or  many  of  the  diseased  bones. 

Fatliologij. — According  to  von  Recklinghausen  and  Stilling,  the 
pathological  changes  in  this  disease,  concerning  the  cause  of  which 
nothing  is  known,  consist  of  an  atrophy  of  the  bone  by  decalcification 
and  lacunar  resorption,  combined  with  the  formation  of  large  amounts 
of  osteoid  tissue  and  the  transformation  of  the  marrow  into  a  connec- 
tive tissue  poor  in  cells.  Multiple  cysts  and  giant-celled  sarcomas  (tumor- 
forming  osteitis  deformans  of  von  Recklinghausen)  may  develop  in  the 
diseased  bones. 

If  tumor-forming  osteitis  deformans  is  limited  to  a  single  bone  it 
may  be  difficult  to  make  a  diagnosis.  It  is  less  difficult  to  differentiate 
between  it  and  giant-celled  sarcomas,  which  may  be  multiple  and  cystic 
(Haberer),  than  between  it  and  nuUtiple  bone  cysts.  The  latter  develop 
in  young  people  in  the  metaphyses  of  long  bones,  especially  in  the  fenuir 
and  humerus,  appearing  as  unilocular,  sometimes  as  nuiltilocular,  cystic 
fibrocartilaginous  tumors  which  gradually  expand  and  destroy  the  bone. 
They  develop  slowly  after  insignificant  injuries,  and  attention  is  often 
first  directed  to  them  by  spontaneous  fractures.  The  majority  of  these 
cysts  are  not  to  be  regarded  as  due  to  a  local  limited  osteodystrophy 
(von  Mikulicz),  but  as  cystic  endoehondrofibromas,  and  should  l)e  classi- 
fied with  tumors.  The  cysts  which  occur  in  osteitis  serosd  ami  ecliiuo- 
coccus  cysts  should  be  thought  of  in  making  a  differential  diagnosis. 

Osteitis  deformans  may  easily  be  confused  with  the  infiannnatory 
bone  thickenings  associated  with  chronic  suppurative  and  syphilitic 
osteitis.  This  mistake  may  be  avoided  by  taking  an  X-ray  picture, 
which  indicates  the  absence  of  or  diminished  amounts  of  calcium  salts, 
and  by  carefully  observing  the  clinical  course  of  the  disease.  Osteitis 
deformans  dift'ei's  from  leontiasis  ossea  in  that  in  the  former  the  eal- 
varium  is  thickened  while  the  base  of  the  skull  and  the  bones  of  the 
face  are  spared. 


750      SURGICAL  DISEASES,   EXCLUDING  INFECTIONS  AND  TUMORS 

Treatment  is  of  no  avail.  The  extremities  become  so  heavy  that  a 
supporting  apparatus  cannot  be  worn.  The  disease  progresses  steadily, 
and  as  there  is  but  little  tendency  to  consolidation,  even  osteotomy  fur 
the  correction  of  deformities  has  been  given  up  (Schuehardt,  Schmie- 
den). If  the  disease  is  limited  to  one  of  the  extremities,  amputation  is 
indicated   ( Schmieden ) . 

(f)    BONE   DISEASE   OCCURRING   IN   MOTHER-OF-PEARL 

WORKERS 

According  to  Englisch  and  Gussenbauer,  elastic  swellings  which  de- 
velop suddenly  with  pain  in  different  bones  are  observed  in  young 
people  who  work  with  mother-of-pearl.  A  circumscribed  bony  thicken- 
ing remains  after  the  swellings  subside.  The  swellings  usually  develop 
upon  the  metaphyses  of  long,  hollow  bones,  but  may  extend  from  here 
to  the  epiphysis  or  diaphysis.  They  also  occur  upon  the  short  and  flat 
bones.  Acute  exacerbations  may  develop,  and  then  the  thickenings' upon 
the  different  bones  enlarge.  There  is  no  suppuration,  necrosis,  or  dis- 
turbances of  the  general  condition.  The  swellings  cause  but  little 
trouble  and  may  subside  spontaneously  if  the  patient  stops  his  work. 

The  frequent  occurrence  of  the  swellings  about  the  vascular  metaph- 
ysis  (cf.  X-ray  pictures  of  injected  bone,  pp.  417-418),  and  Gussen- 
bauer's  demonstration  of  dust  of  mother-of-pearl  in  the  lungs  of  dogs 
after  inhalation  experiments,  justify  the  view  advanced  by  Englisch  and 
Gussenbauer  that  the  inflammatory  changes  follow  the  haematogenous 
deposition  of  particles  of  pearl  dust  or  its  organic  constituent  (con- 
chiolin)  in  the  bones.  Broca  and  Tridon  have  made  the  only  patho- 
logical investigations.  They  merely  found  evidences  of  a  rarefying 
osteitis  in  pieces  of  bone  which  had  been  chiseled  away. 

It  is  possible  to  confuse  this  disease  with  the  subacute  forms  of  sup- 
purative osteomyelitis. 

It  is  not  necessary  to  institute  any  special  line  of  treatment,  as  the 
lesions  heal  spontaneously  when  the  patient  changes  his  occupation. 

LiTKUATUUE. — Broca  und  Tridon.  Ostooinyelite  des  nacriers  (Conchiolin-ostitis). 
Revue  de  chir,  1003. — Guf^senbauer.  Die  Knoohenontzi'iruhmgen  der  Perlmutter- 
drechslor.  Arch.  f.  kliii.  Chir.,  Bd.  18,  187'),  p.  mo.—llaberer.  Zur  Kasuistik  der 
Krioelu-iizysten.  Arch.  f.  kliii.  Ciiir.,  lid.  7(5,  1905,  p.  5r^9.—Heincke.  Ein  Fall 
von  iiiul(ij)len  Knochenzystcii.  licit  r.  z.  klin.  Chir.,  Bd.  40,  1903,  p.  481. — Ktistcr. 
IJeber  fibnise  Ostitis  mit  Demonstration.  Chir.  Kongr.-Verhandl.,  1897,  II,  j).  333 
und  Disk.  Schlange  I,  p.  134. — v.  Mikulicz.  Osteodystrophia  cystica.  Zentralbl.  f. 
Chir.,  1904,  p.  1323. — Schmieden.  Beitrag  zur  Kenntnis  der  Osteomalacia  chronica 
deformans  hypertrophica  (Paget).  Deutsche  Zeitschr.  f.  Chir.,  1904,  Bd.  70,  p.  207. — 
M.  li.  Schmidt.  Osfeilis  deformans.  Ergehnissc  d.  allg.  Path,  von  Lubarsch  u.  Ostertag. 
5.  Jahrg.,  1900,  \).  949. — Schuchnrdt.  Die  K'raidvheiten  tier  Knochen  und  Gelenke. 
Deutsche  Chir,,  1899,  pp.  114-132,  149. 


PART   VI 
TUMORS 


I.    GENERAL    PART 
CHAPTER    I 

DEFINITION    AND    CLASSIFICATION 

Definition. — By  the  terms  true  or  autonomous  tumor,  new  growth, 
neoplasm,  and  blastoma  is  not  to  be  understood  every  cellular  pro- 
liferation resulting  in  the  enlargement  of  the  tissues  or  organs  involved, 
but  only  those  new  formations  of  tissues  which  have  very  definite  char- 
acteristics, among  which  the  following  are  the  most  important : 

1.  The  development  of  a  true  tumor  is  entirely  independent  of  the 
organism,  except  that  it  receives  nutrition  from  it.  The  growth  fulfills 
no  physiological  function. 

2.  The  structure  of  the  tumor  varies  more  or  less  from  that  of  the 
surrounding  normal  tissues,  and  is  atypical  even  from  the  first  begin- 
nings of  its  development. 

3.  A  tumor,  as  a  rule,  has  no  typical  limits  of  growth.  There  is 
always  the  tendency  to  progressive  growth,  notwithstanding  the  fact 
that  there  may  be  long  periods  in  which  the  tumor  remains  stationary 
or  even  temporarily  decreases  in  size.  A  permanent  cessation  of  growth 
is  observed  in  many  benign  tumors.  Spontaneous  involution  is  rare. 
Of  course  necrosis,  followed  by  disappearance  of  the  tumor,  cannot  be 
regarded  as  involution  strictly  speaking. 

4.  The  causes  and  the  nature  of  tumor  formation  are  unknown.  All 
hypertrophies  and  hyperplasias,  inflammatory  swellings,  and  infectious 
granulomas  (occurring  in  tuberculosis,  actinomycosis,  glanders,  lepro.sy, 
syphilis,  rhinoscleroma)  are  to  lie  distinguished  from  true  tumors.  Usu- 
ally only  the  connective  ti.ssues  are  involved  in  the  inlhinimatory  growth, 
and  the  tissues  which  are  formed  do  not  differ  greatly  from  the  nor- 
mal. The  embryonal  charaeter  of  tlie  tissue  in  intlaiimiatory  growths  is 
maintained  and  cicatrization  prevented  l)y  some  definite  cause  (irritation 
of  all  kinds  or  bacterial  infections),  and   when  the  cause  is  removed 

751 


752  GENERAL   PART 

the  embryonal  tissues  become  transformed  into  tissues  of  the  adult  type. 
Yet  there  are  tumors,  as  Virchow  long  ago  emphasized,  that  can  scarcely 
be  differentiated  from  hyperplastic  new  growths  of  an  inflammatory 
nature,  and  the  cells  composing  them  scarcely  exceed  the  limits  of 
normal  growth. 

Cysts. — Sacs  filled  with  fluid  or  caseous  contents  should  only  be 
classified  with  true  tumors  when  they  have  developed  from  solid  tumors 
(degeneration  cysts,  cystadenoma)  or  when  the  tissues  comprising  their 
walls  have  proliferated  and  have  assumed  the  characteristics  of  new 
growths    (epithelial,  dermoid,  and  teratoid  cysts). 

Classification. — The  classification  of  tumors  has  been  based,  since 
Yirchow's  classification,  upon  their  histologic  and  histogenetic  relations. 
According  to  Ribbert — whose  classification  is  followed  in  greater  part, 
for  a  classification  based  upon  a  clinical  view-point  alone  is  impossible — 
tumors  may  be  divided  into  the  six  following  groups : 

I.  Tumors  developing  from  connective  tissues. 

1.  The. fibroma  (composed  of  fibrous  tissue). 

2.  The  lipoma  (composed  of  fat). 

3.  The  chondroma  (composed  of  cartilage). 

4.  The  osteoma  (composed  of  bone). 

5.  The  angioma  (composed  of  blood  vessels). 

6.  The  sarcoma  (composed  of  unripe  connective  tissues,  rich  in 

cells)  with  its  subdivisions: 
(a)    Composed  of  cells  of  any  of  the  connective  tissues. 
(?>)   Composed  of  cells  resembling  lymphoid  cells. 

(c)  Composed  of  mucoid  tissue — myxoma,  myxosarcoma. 

(d)  Composed  of  pigment  cells — melanoma,  chromatopJw- 
roma. 

II.  Tumors  developing  from  muscular  tissue. 

1.  The  rhabdomyoma   (composed  of  striated  muscle). 

2.  The  leiomyoma  (c(m]i)osed  of  smooth  muscle). 

III.  Tumors  composed  of  nervous  tissue. 

1.  The  neuroma  (developing  from  nerves  and  ganglion  cells). 

2.  The  glioma   (develoi)ing  from  glia  cells). 

IV.  Timiors  developing  fi'om  epithelium. 

1.  The  fibro-epithelial  tumoi-s. 

2.  The  carcinoma  with  its  subdivisions  depending  upon  the  ori- 

gin of  the  epithelium. 

V.  Tiiiii(ii-s  composed  o!"  ciidothelium. 
The  endothelioma. 

VI.  Mixed  tumors. 


ETIOLOGY   OF   TUMORS  753 

According  to  Vircliow's  classification,  Avhicli  is  still  valued  highly, 
there  are  liistioid  tumors,  the  structure  of  which  resembles  closely  the 
structure  of  normal  tissues  (e.  g.,  fibroma,  lipoma,  osteoma)  ;  organoid 
tumors,  which  resemble  in  structure  the  different  viscera  of  the  body, 
being  composed  of  an  interstitial  tissue  and  a  parenchyma;  and  sys- 
temadoid  or  teratoid  tumors,  with  a  complicated  organic  structure  re- 
sembling that  of  the  body  or  a  part  of  it. 


CHAPTER    II 

ETIOLOGY   OP    TUMORS 

The  etiology  of  tumor  formation  is  still  ol)scure.  It  is  known  that 
there  are  a  number  of  conditions  which  favor  the  development  of 
tumors,  but  no  one  alone  is  sufficient  to  explain  the  beginning  of  a 
new  growth.  Naturally,  as  the  etiology  is  obscure,  the  greatest  impor- 
tance has  been  attached  to  the  conditions  which  apparently  favor  growth. 

1.  The  Theory  of  Foetal  Residues  or  Embryonic  Rests. —  |"  This  theory 
originated  in  Vircliow's  suggestion  that  in  ossification  of  cartilage  small 
islets  might  be  left,  which  subsequently  grow  and  develop  into  enchon- 
dromas ;  the  idea  was  at  a  later  date  expounded  by  Cohnheim  to  include 
all  tumors." — Rose  and  Carless,  "  ]\fanual  of  Surgery,"  p.  177.] 

According  to  this  theory,  tumors  develop  from  germinal  tissiie  which 
has  been  displaced  or  separated  from  its  normal  connecticm  during  em- 
bryonic development,  or  from  tissues  which  ordinarily  undergo  involu- 
tion, but  have  maintained  their  embryonal  characteristics ;  in  a  certain 
sense,  then,  from  local  tissue  malformations  (Cohnheim,  Ziegler).  Epi- 
dermoids and  dermoids  develoj)  from  displaced  ectoderm ;  entero-cysts 
from  displaced  germinal  mucous  membrane;  tumors  from  displacinl 
adrenal,  thyroid,  and  mammary  rests,  from  branchial  clefts,  the  ui-achus 
and  vitelline  duct;  true  mixed  and  teratoid  tumors  from  dofiiiant  dis- 
placed embryonal  tissue.  To  these  may  be  added  Vircliow's  heterolo- 
gous tumors,  which  undoubtedly  develop  from  displaced  germinal  tis- 
sue. They  differ  from  the  homologous  tumors  in  that  they  develop  in 
tissue  or  organs  to  which  they  bear  no  resemblance  histologically  (e.  g., 
lipoma  of  the  pia  mater  and  brain,  myoma  within  the  kidney,  chon- 
droma in  the  viscera,  and  tumors  developing  from  congenital  anomalies 
such  as  pigmented  moles  of  the  skin).  Finally,  it  is  not  to  be  doubted 
that  a  number  of  tumors,  such  as  angiomas,  lipomas,  fibromas,  clion- 
dromas,  myomas,  sarcomas,  which  are  often  congenital  and  associated 
with  all  sorts  of  malformations  develop  from  embryonic  rests. 


754  GENERAL  PART 

2.  Relation  Between  Inflammation  and  Trauma  and  Tumor  Formation. 

— That  inflammation  and  trauma  not  infrequently  precede  tumor  forma- 
tion is  well  known  to  every  clinician.  It  is  not  known,  however,  in  what 
way  the  inflannnation  or  trauma  stimulates  the  tissues  to  atypical  pro- 
liferation. 

Tissue  changes  resulting  from  chronic  irritation  of  different  sorts 
and  from  chronic  inflammation  prepare  the  way  for  the  development 
of  tumors.  It  is  well  known  that  the  chronic  eczema  developing  in 
workers  in  paraffin  and  coal-tar,  the  inflammatory  condition  of  the  scro- 
tum in  chimney-sweeps,  the  chronic  balanitis  in  phimosis,  and  the 
chronic  dermatitis  of  the  hands  in  X-ray  workers  favor  the  develop- 
ment of  carcinoma.  Besides,  there  is  a  tendency  for  carcinomas  to  de- 
velop in  chronic  ulcers,  such  as  varicose  ulcers  of  the  leg  and  chronic 
ulcers  of  the  stomach,  in  traumatic  ulcers  of  the  tongue  and  cheek 
(produced  by  carious  teeth),  in  tuberculous  and  syphilitic  ulcers  of  the 
skin,  in  chronic  fistula;  following  necrosis  of  bone  or  developing  about 
the  rectum,  and  in  scars  resulting  from  the  healing  of  chronic  ulcers. 
Hyperplastic  new  growths,  such  as  leucoplakia,  hyperkeratosis,  papillary 
warts,  nuicous  polypi  forming  upon  an  inflammatory  base,  not  infre- 
quently develop  into  carcinoma,  occasionally  into  sarcoma  or  melanoma. 

The  causal  relationship  between  pipe  smoking  and  shaving  and 
carcinoma  of  the  lip,  between  pressure  upon  a  definite  area  and  the 
development  of  lipomas,  etc.,  is  less  obscure  than  that  between  new 
growths  and  the  conditions  above  mentioned. 

A  single  trauma  may  be  regarded  as  the  cause  of  a  tumor  only  in 
case  of  epithelial  cysts  in  the  palm  of  the  hand.  These  cysts  develop 
from  pieces  of  skin  which  have  been  displaced  and  carried  into  the 
deeper  tissues  in  punctured,  incised,  and  gunshot  wounds. 

In  all  other  cases  it  is  impossible  to  demonstrate  a  direct  relation- 
ship between  trauma  and  tumor  formation.  It  is  possible  that  when  a 
sarcoma  develops  at  the  seat  of  a  fracture,  a  carcinoma  of  the  stomach 
after  a  contusion  of  that  abdominal  wall,  that  the  tumor  was  already 
present  at  the  time  of  the  injury,  but  had  given  rise  to  no  symptoms, 
and  that  attention  was  drawn  to  it  by  the  injury. 

Statistics  concerning  the  relationship  between  trauma  and  tumor 
formation  are  not  convincing,  as  the  tendency  is  too  deeply  rooted  in 
the  huiMjin  mind  to  associate  a  local  ailment  with  a  local  cause  (Cohn- 
heim). 

It  iiKiy,  tiowcvci',  ])(>  i-egarded  as  certain  that  trauma  and  chronic 
inllanimalioii,  slimuhiting  as  they  do  the  regenerative  activity  of  the 
tissues,  exercise  a  marked  influence  iipoii  the  growth  of  preexisting 
tumors.  This  is  an  impoi-tant  point  in  accident  insurance,  as  the  com- 
pany  can   be  lidd   li;i])|('   only   when   a   direct   relationship  between   the 


ETIOLOGY   OF   TUMORS  755 

accident  and  the  lesion  can  be  demonstrated.  Jt  is  well  known  how 
much  more  rapidly  a  malignant  tumor  grows  after  incomi)]i'te  excision 
or  cauterization.  Jn  the  different  statistics  the  causal  relationship  be- 
tween trauma  and  tumor  formation  varies  from  2.5  to  44.7  per  cent 
(Borst). 

3.  Heredity  and  Congenital  Predisposition. — Heredity  or  congenital 
predisposition  seems  to  be  an  etiological  factor  in  a  certain  number  of 
cases.  It  seems  to  play  a  part  in  the  development  of  some  na'vi,  angio- 
mas, multiple  fibromas  of  the  skin  and  nerves,  lipomas,  enchondromas, 
and  exostoses  which  are  either  present  at  birth  or  develop  later  in  life. 
It  is  remarkable  that  tumors  not  infrequently  develop  in  the  members 
of  the  same  family,  even  in  the  same  organs.  One  then  speaks  of  a 
local  predisposition  of  certain  parts  of  the  body  or  of  certain  organs. 
In  carcinoma,  according  to  Roger  Williairis,  heredity,  which  may  even 
extend  to  the  part  involved,  may  be  established  in  10.5  per  cent  of  the 
cases  (Liicke  and  Zahn). 

The  different  views  concerning  the  development  of  tumors  may  at 
the  present  time  be  divided  into  two  groups.  To  the  first  group  belong 
the  hypotheses  of  Cohnheim  and  Ribbert,  according  to  which  tumors 
develop  from  cells  which  have  been  separated  from  their  organic  con- 
nections and  displaced  either  during  emlu'vonal  or  extrauterine  life. 
In  the  second  group  may  be  combined  all  those  hypotheses  according 
to  which  tumors  develop  from  cells  normally  placed,  but  which  have 
acquired  the  property  of  unrestrained  growth  as  the  result  of  the  action 
of  some  unknown  influences  (irritation  of  different  sorts)  (Virchow) 
or  perhaps  even  of  parasites. 

4.  Cohnheim's  Theory. — According  to  Cohnheim,  all  true  tumors  de- 
velop from  superfluous,  misplaced,  or  abnormally  persisting  centers  of 
embryonic  tissue  which  may  be  stimulated  to  growth  by  a  number  of 
diffei'ent  causes  (increased  nutrition,  decrease  of  resistance  to  growth, 
physiological  increase  or  decrease  of  local  or  general  growth,  Borst). 

Dermoids  and  teratomas,  tumors  of  accessory  organs  and  displaced 
adrenal  rests,  cysts  arising  from  the  branchial  clefts,  the  urachus.  vitel- 
line and  thyreoglossal  ducts,  which  undoubtedly  develop  from  displaced 
or  non-involuted  embryonal  tissue,  support  this  theory. 

Cohnheim's  theory,  however,  lacks  anatomical  foundation,  and  there 
are  a  number  of  facts  which  make  it  impossible  to  ap])ly  it  to  the 
development  of  tumors  in  general.  In  the  first  place  it  is  scarcely 
possible  to  conceive  that  tumors  developing  in  advanced  life  have  sprung 
^  from  displaced  tissues  which  have  maintained  their  embryonal  char- 
acteristics through  all  the  preceding  years.  Besides  the  transplantation 
of  embryonal  tissues  into  animals  of  the  same  species  has  never  been 
followed  by  tumor  formation,  the  embryonal  tissue,  if  it  has  remained 


756  GENERAL   PART 

alive  and  has  developed,  becoming  transformed  into  tissues  resembling 
more  or  less  elosely  those  of  the  adult  type  (Zahn,  Leopold,  Birch- 
Hirschfeld  and  Garten,  Fere,  Schmieden,  Wilms,  and  others). 

5.  Ribbert's  Theory. — According  to  Ribbert,  true  tumors  develop 
from  germinal  tissue  Avliich  is  either  displaced  during  development  or 
later  in  life  by  traumatism  or  after  inflammatory  processes.  When  dis- 
placed this  germinal  tissue  is  separated  from  its  normal  physiological 
connections  and  becomes  an  independent  center  of  growth.  Ribbert 
believes  that  the  independence  of  this  tissue  explains  satisfactorily  its 
unlimited  growth,  for  the  tension  of  the  tissues  no  longer  exercises  a 
restraining  influence,  as  the  normal  tissues  do.  Inflammatory  hyper- 
ivmia,  and  the  hypera^mia  associated  with  different  forms  of  trauma, 
favor  rapid  and  excessive  proliferation. 

-  The  development  of  epithelial  cysts,  such  as  occur  in  the  palm  of  the 
hand,  supports  Ribbert's  theory  of  the  post-embryonal  separation  of 
groui)s  of  cells  from  their  organic  connections.  These  small  cysts  de- 
velop from  pieces  of  epidermis  which  are  carried  beneath  the  cutis  by 
foreign  bodies  or  by  injuries.  The  separation  and  displacement  of 
groups  of  cells  can  be  frequently  demonstrated  in  chronic  inflammatory 
processes.  The  composition  of  the  germinal  tissue  determines  the  char- 
acter of  the  tumor;  for  example,  a  flbroma  develops  from  displaced 
fibrous  tissue,  a  lipoma  from  fatty  tissue,  a  carcinoma  from  epithelium. 
A  sarcoma  develops  if  the  germinal  connective-tissue  matrix  remains 
of  an  embryonal  type. 

This  theory,  like  Cohnheira's,  attempts  to  place  tumor  formation 
upon  a  single,  definite  basis.  It  has  gained  more  and  more  recognition  of 
late.  It,  however,  also  presupposes  the  action  of  some  unknown  influence, 
for  apparently  the  displaced  cells  are  incapable  of  spontaneous  prolif- 
eration, and  it  has  been  established  by  a  number  of  experiments  that 
tumors  do  not  develop  after  the  transplantation  of  tissue  of  various 
kinds.  Besides,  in  many  diseases  cellular  and  tissue  emboli  (bone 
marrow  and  giant-cells,  fat,  liver,  and  placental  cells,  and  chorionic 
villi)  are  deposited  in  viscera  and  other  tissues  without  giving  rise  to 
tumor  formations.  Ehrlich's  work  throws  some  light  upon  the  nature 
of  the  unknown  influence  which  prevents  proliferation  in  these  cases. 
Accoi-ding  to  Ehrlich's  tlicory,  the  organism  possesses  a  certain  protec- 
tive mcclianism  (atreptie  imniunily)  which  prevents  abnormal  growth. 
Wlien  tlic  immunity  is  decrc.ised  the  tumor  germs  may  take  from  the 
liudy  tlif   r<)ii(l-stuli('s  re<|nii'('(l   for  ])r()lif('ration. 

Accoi-(ling  lo  llause!',  tumor  formtition  may  begin  in  cells  normally 
placed.  P>nt  in  111  is  thcoiy  it  must  be  presupposed  that  there  are  cer- 
liiin  special  hiologienl  changes  in  the  cells  which  lead  to  tnuioi-  forma- 
tion.     Jt   may    he   Mssnined,    Cor  exiiinpl(%   that  the  normal   cells,  which 


ETIOLOGY   OF  TUMORS  757 

may  be  stimulated  to  increased  proliferation  by  all  sorts  of  irritation, 
gain  an  increased  energy  for  growth  while  their  functional  activity  is 
decreased  (Benekc,  Ilauser,  Lubarsch,  0.  Israel),  or  that  they  assume 
toxic  properties  (Marchand)  which  destroy  adjacent  tissues  and  render 
an  infiltrating  growth  possible.  Thiersch  attempted  to  explain  the 
development  of  carcinomas  by  supposing  that  the  connective  tissues 
undergo  a  certain  atrophy,  associated  with  a  relaxation  of  their  strata, 
and  that  they  then  no  longer  oppose  a  barrier  to  the  epithelium  still 
possessed  of  its  full  power  of  reproduction.  Von  Hansemann  presup- 
poses in  malignant  tumors  an  anaplasia  of  the  cells  from  which  they 
develop,  and  therefore  the  tumor  remains  of  a  primitive  structure  as 
the  anaplastic  cells  are  not  capable  of  differentiation  into  tissues  of  an 
adult  type.  According  to  this  theory,  anaplastic  cells  respond  to  stimu- 
lation by  developing  into  malignant  tumors,  while  normal  cells  form 
merely  hyperplasias  in  the  broadest  sense  of  the  word.  It  is  a  fact 
that  tumor  cells  are  very  primitive  in  structure,  resembling  closely  the 
embryonal  prototypes  of  the  tissue  from  which  they  spring;  for  exam- 
ple, large  connective-tissue  cells  which  do  not  form  intercellular  fibrillie 
are  found  in  sarcomas;  epithelial  cells  which  do  not  cornify  and  do 
not  secrete  are  found  in  many  carcinomas  of  the  skin  and  mucous  mem- 
brane respectively.  Ribbert  does  not  consider  this  return  of  cells  from 
an  adult,  and  differentiated  to  a  primitive  and  simple  type  as  necessary 
for  tumor  formation,  but  merely  as  a  factor  which  favors  growth  when 
tumors  develop  from  fully  diff'erentiated  elements. 

6.  Parasitic  Theory. — Bacteria  w^hich  have  been  found  in  tumors  have 
been  shown  to  be  merely  harmless  saphrophytes  and  not  the  essential 
cause.  Critical  examination  has  shown  that  the  blastomyces,  protozoa, 
rhizopoda,  infusoria,  and  sporozoa  (among  the  latter  coccidia,  gre- 
garinjp,  plasmodia,  psorospermia)  which  have  been  described  in  tumors 
were  altered  tumor  cells  undergoing  regressive  changes,  such  as  vacuole, 
keratohyalin,  and  colloid  formation,  or  cell  inclusions,  consisting  in  part 
of  tumor  cells,  in  part  of  degenerated  leucocytes  or  epithelium  (vide 
Borst).  L.  Pfeiffer  and  Adamkiewicz  regard  the  carcinoma  cells  proper 
as  the  parasites. 

A  number  of  different  investigators  (Busse,  Jiirgens,  Schiiller, 
Sjobring,  and  others)  have  been  successful  in  cultivating  parasites  from 
fresh  tumor  tissue,  but  they  have  never  been  able  to  produce  by  inocu- 
lation any  changes  which  could  be  regarded  other  than  of  an  inflam- 
matory nature. 

Only  the  transplantation  of  living  tumor  tissue — for  example,  the 
transplantation  of  carcinomatous  tissue  from  one  to  another  part  of  a 
patient  suffering  from  the  disease  (Hahn,  von  Bergmann,  Cornil),  or 
of  tumor  tissue  from  one  animal  to  another  animal  of  the  same  species 


758  GENERAL   FART 

(dog,  rat,  mouse)  (Novinsky,  Weber,  Hanau,  von  Eiselsberg,  Geissler, 
Moran,  Jenseu  and  others) — has  led  to  any  definite  results. 

The  experiments  made  by  Gaylord,  of  the  New  York  State  Cancer 
Laboratory,  and  by  Ehrlich  have  given  the  most  important  results,  which 
are  also  of  significance  in  another  direction.  These  investigators  have 
been  able,  by  carrying  inoculations  through  a  number  of  mice,  to  in- 
crease the  power  of  growth  or  virulence  of  the  tumor  masses,  just  as 
the  virulence  of  bacteria  is  increased  by  passing  them  through  animals, 
so  that  finally  almost  all  inoculations  with  the  most  virulent  material 
are  successful.  Sometimes  in  these  experiments  a  carcinoma  becomes 
transformed  into  tissue  resembling  that  of  a  sarcoma  or  into  pure  forms 
of  sarcomas,  as  the  epithelium  is  finally  suppressed  by  the  more  rapidly 
proliferating  stroma.  As  regards  the  parasitic  theory,  all  these  find- 
ings (similar  to  the  so-called  inoculation  recurrences  in  the  scar  after 
operations  for  carcinoma)  merely  show  that  encapsulated,  well-nour- 
ished tumor  cells  may  develop  in  other  parts  of  the  body,  being  similar, 
therefore,  to  metastatic  growths.  Transplantation  experiments  also  show 
that  the  tumor  cells  may  retain  their  growth  energy,  not,  however,  that 
a  parasite  has  been  inoculated  with  the  tumor  tissue  and  has  caused  the 
development  of  a  new  growth. 

From  a  clinical  view-point,  practically,  only  facts  which  relate  to 
carcinoma  have  been  employed  to  sustain  the  parasitic  theory  of  the 
origin  of  tumors  (Czerny)  ;  such  as,  that  carcinomas  develop  upon  parts 
most  frequently  exposed  to  external  influences  (face,  neck,  hands)  ; 
are  most  common  where  wounds  are  common,  and  apparently  provide 
infection  atria  (ulcers  of  all  sorts,  fistula^,  eczema,  scars  resulting  from 
wounds  or  ulcers,  fissured  nipples,  erosions  of  the  cervix)  ;  or  where 
there  are  changes  resulting  from  chronic  irritation  (chronic  inflam- 
mation of  the  skin,  hyperkeratosis,  seborrha?a,  eczema,  leucoplakia, 
chronic  balanitis  in  phimosis).  The  frequent  involvement  of  those  parts 
of  the  gastro-intestinal  tract  most  often  exposed  to  traumatic  and  in- 
fUuimuitory  irritation  (margin  of  the  tongue  injured  by  carious  teeth, 
a'sophagus,  cardia,  pylorus,  flexures  of  the  large  intestines,  rectum)  also 
supports  this  theory.  Uncleanliness  seems  to  play  a  role  and  to  speak 
for  ;i  ])ai-asitic  cause  (fre(iuent  occurrence  of  carcinoma  of  the  face 
among  the  poorer  classes,  of  cancer  of  the  moutli  when  the  teeth  are 
badly  cared  for,  of  carcinoma  of  th(^  })i'east  when  the  nipples  are  dirty 
and  scaly).  The  occurrence  of  nniltiple  carcinomas  in  the  gastro-intes- 
'i";il  If.H'l;  tlic  few  cases  of  so-called  implantation  carcinomas,  for  ex- 
ample, iinplanlalion  fi-om  the  tongue  to  tlu^  mucous  meml)i'anes  of  the 
clicek  lying  opposile  (Liicke),  from  the  lower  to  th<'  upper  lip  (von  Berg- 
maiui).  I'lom  one  pciiloncil  .sin-face  to  llie  oi)posite  (Beneke)  ;  and  the 
occurrence  of  c;ifcinniii;i   in  many  members  of  the  same  family  or  in  a 


FORM,   GROWTH,   AND   CLINICAL   SIGNIFICANCE   OF   TUMORS       759 

nunibor  of  families  liviny  in  the  same  house  or  iieiiihborhood  have  been 
supposed  b}'  many  to  speak  for  a  parasitic  origin.  Broca  has  carefully 
reported  the  history  of  a  family  in  which  sixteen  out  of  twenty-six 
members,  representing  three  generations,  were  aftlicted  with  carcinoma. 
Objections  to  the  Parasitic  Theory. — There  nve  a  number  of  objec- 
tions Avhich  may  be  raised  against  the  parasitic  theory,  and  even  the 
frequent  involvement  of  the  parts  above  mentioned  may  be  satisfactorily 
explained  without  resorting  to  it.  In  the  first  place,  certain  typas  of 
tissue  are  always  reproduced  in  the  different  tumors,  even  in  the  dif- 
ferent varieties  of  carcinomas.  How  would  it  be  possible  that  in  a 
parasitic  infection  only  one  definite  form  of  cell  is  always  stimulated 
to  proliferation  (for  example,  only  the  epithelium),  while  the  connec- 
tive, endothelial,  and  glandular  tissues  are  acted  upon  by  the  infection 
at  the  same  time?  In  this  case  there  must  be  at  least  as  many  varieties 
of  parasites  as  there  are  varieties  and  sub-varieties  of  tumors,  leaving 
out  of  consideration  mixed  tumors,  the  complicated  structure  of  which 
alone  speaks  against  a  parasitic  origin.  The  development  of  metastases, 
composed  of  cells  resembling  those  of  the  primary  growth,  and  the 
growth  of  the  tumor  without  stimulating  the  surrounding  tissues  to 
proliferation  are  weighty  arguments  against  the  theory  (cf.  Borst, 
Ribbert). 


CHAPTER    III 

FORM,    GROWTH,    AND    CLINICAL    SIGNIFICANCE    OF    TUMORS 

Different  Forms  which  Tumors  may  Assume. — Among  the  many  forms 
which  tumors  situated  superficially  or  deeply  may  assume,  the  round, 
nodular  form  is  the  most  connnon.  As  a  tumor  develops  it  may  change 
into  a  tuberculated,  bulbous  mass,  the  form  being  influenced  by  ana- 
tomical relations.  The  following  forms  of  tumors  are  differentiated 
upon  the  surface  of  the  skin  and  mucous  membranes :  Tumors  with 
broad  and  thin  pedicles;  fungoid,  pendulous,  verrucous,  villous,  papil- 
lary tumors  w'ith  numerous  thornlike  elevations;  and  caulitlowerlike 
growths  with  a  dendritic  arrangement  of  the  proliferating  tissues.  Sev- 
eral different  forms  may  be  combined  in  the  same  tumor. 

Expansive  and  Infiltrating  Growth. — A  tumor,  as  it  grows,  pushes 
aside  or  infiltrates  the  surrounding  tissue,  the  former  being  known  as 
expansive,  the  latter  as  infiltrating  growth.  The  increase  in  the  size 
of  a  tumor  is  due  to  the  proliferation  of  its  constituent  parts  alone, 
and  not  to  the  transformation  of  the  infiltrated  tissue  into  tumor  cells 
and  their  proliferation   to   form  tumor  masses,   as   was   formerly  con- 


760  GENERAL   PART 

sidered  to  be  the  case.  A  tumor  growing  by  expansion  lias  sharp  bound- 
aries, may  easily  be  separated  from  the  surrounding  tissues,  and  has 
a  distinct  capsule  formed  by  the  thickening  and  reactive  proliferation 
of  the  surrounding  tissues;  while  an  infiltrating  tumor  has  more  or 
less  indistinct  boundaries  and  is  intimately  attached  to  the  surrounding 
tissue.  Sometimes  a  growth  which  is  expansive  in  the  beginning  later 
becomes  infiltrating. 

A  tumor  is  always  nourished  by  blood  vessels,  w'hich  enter  it  from 
the  surrounding  tissues.  In  slowly  growing  tumors  the  blood  supply  is 
usually  sutfieient  to  nourish  the  entire  tumor,  wdiile  in  rapidly  growing 
tumors  it  is  often  insufficient,  and  parts  of  the  tumor  may  become 
necrotic  during  its  later  development.  Frequently  the  necrosis  is  pre- 
ceded by  fatty  and  nuicoid  degeneration.  Often  tumors,  especially  those 
with  long  pedicles,  become  (Edematous  as  the  result  of  venous  stasis. 
When  stasis  occurs,  fluids  may  be  pressed  from  the  cut  surface  of  the 
tumor  as  from  a  sponge.     It  then  resembles  closely  myxomatous  tissue. 

Regressive  Changes. — Regressive  changes  occur  when  the  infiltrat- 
ing growth  invades  and  occludes  the  blood  vessels.  The  regressive 
changes  lead  to  the  formation  of  cavities  in  the  interior  of  tumors,  of 
ulcers  upon  the  surface,  and  not  infrequently  to  contraction  of  the 
conn  ret  ive  tissues. 

Clinical  Significance. — The  clinical  significance  of  tumors  rests  in 
the  first  place  upon  the  harm  they  do,  which  may  be  the  direct  result 
of  their  enlargement  and  other  properties  of  tumor  tissue.  In  expansive 
growths  the  amount  of  harm  done  the  organism  depends  entirely  upon 
the  importance  of  the  structure  or  of  the  organ  pressed  upon  or  dis- 
placed. For  example,  pressure  upon  large  vessels  causes  circulatory 
disturbances;  upon  nerves  and  the  spinal  cord,  irritation  or  paralysis; 
upon  tlic  l))'ain,  severe  symptoms  or  death;  while  a  tumor  upon  the  sur- 
face of  the  body,  even  if  very  large,  may  cause  but  slight  inconvenience. 
Infiltr-ating  growths  do  much  more  harm,  as  they  press  upon  the  infil- 
li'iilcd  1  issue,  wliich  is  destroyed  (e.  g.,  destruction  of  an  entire  viscus 
and  rci)ljieenient  l)y  tumor  masses,  erosion  of  large  ves.sels). 

The  harmful  effects  of  tumors  may  also  be  due  to  recurrences,  metas- 
ta.ses,  <ni(l  llic  s(»-(';ill('<]  cachexia  which  they  induce. 

Recurrence  of  Tumors. — HecuiTeiiccs  occur  after  removal  only  when 
part  of  the  tumor  tissues  has  been  left.  Naturally  this  is  much  more 
freciuent  when  liimoi's  iii(illi"ite  the  surrounding  tissues  than  Avhen 
they  an;  cii'cuniseribed  and  encapsulated.  The  recurrences  may  de- 
velop in  the  area  from  which  the  tumor  was  removed,  or,  if  the  cells 
have  been  carried  by  the  lympli  stream,  in  sui-rounding  structures. 

Metastatic  Growths. — By  metastatic  tumors  are  understood  those 
(levelopiMg  seeoiidaiy    to   the  pi'imary   growth   in. distant  parts  of  the 


FORM,   GROWTH,   AND   CLINICAL   SIGNIFICANCE   OF   TUMORS       761 

body.  They  develop  from  tumor  tissue  (cells,  groups  of  cells,  or  pieces 
of  tumor  tissue)  which  has  been  carried  by  the  lymphatic  vessels  and 
blood  vessels  to  distant  parts,  after  one  or  the  other  of  these  has  been 
invaded  by  the  infiltrating  growth.  The  cells  carried  by  the  lymph 
stream  are  arrested  in  the  adjacent  lymph  nodes  and  develop  into  sec- 
ondary tumors.  If  the  tumor  cells  pass  into  blood  vessels,  as  is  fre- 
quently the  case  in  advanced  carcinomas  and  sarcomas,  or  into  the 
thoracic  duct  from  some  of  the  smaller  lymphatic  vessels,  they  are  dis- 
tributed and  deposited  in  different  parts  of  the  body  in  the  form  of 
emboli  (ha^natogenous  metastases). 

If  the  tumor  invades  the  veins  of  the  systemic  circulation,  tumor 
masses  ma,y  be  carried  by  the  blood  stream  into  the  lungs.  If  the  em- 
boli are  small  enough  to  pass  through  the  capillaries  of  the  lung  (6  ju. 
in  width),  they  are  carried  to  the  left  heart,  and  from  here  into  the 
arterial  system,  to  lodge  where  there  is  a  hypertemia  or  where  the  capil- 
laries are  very  narrow  (liver,  kidney,  more  rarely  other  viscera,  bone, 
skin).  Embolism  of  one  of  the  larger  branches  of  the  pulmonary  artery 
may  cause  immediate  death.  If  the  tumor  tissue  gains  access  to  the 
portal  vein,  it  will  first  be  deposited  in  the  liver.  It  cannot  be  estimated 
how  many  tumor  cells  die  in  the  lymph  and  blood  stream  or  fail  to 
develop  after  they  are  deposited.  It  is  not  to  be  doubted  that  degen- 
erating non-viable  cells  as  well  as  viable  cells  are  carried  in  the  emboli, 
and  that  all  of  them  are  not  able  to  form  metastases.  More  rarely  the 
following  varieties  of  extension  occur  by  way  of  the  lymphatic  and 
blood  vessels:  (1)  Continuous  extension  by  growth  of  the  tumor  ele- 
ments within  the  lumen  of  the  vessel  (e.  g.,  a  carcinoma  grows  for  some 
distance  in  a  lymphatic  vessel  to  an  adjacent  node,  extension  of  car- 
cinomas of  the  stomach  and  intestines  into  radicles  of  the  portal  vein, 
and  of  a  sarcoma  or  hypernephroma  of  the  kidney  through  the  renal 
vein  into  the  inferior  vena  cava,  and  from  here  into  the  right  heart)  ; 
(2)  retrograde  extension,  the  tumor  tissue  developing  against  the  cur- 
rent of  the  vessel  involved.  This  may  be  the  ease  if  there  is  a  mai-ked 
venous  stasis  and  the  pulsation  transmitted  to  the  veins  is  more  power- 
ful than  the  blood  current  (Ribbert). 

The  occlusion  of  one  of  the  principal  lymphatic  channels  may  so 
change  the  direction  of  the  lymph  stream  that  tumor  cells  may  be  car- 
ried in  a  direction  opposite  to  that  in  which  the  stream  normally  flows 
in  vessels  entering  into  the  collateral  circulation.  A  continuous  gi-owth 
within  the  lymphatics  extending  to  adjacent  nodes  is  more  frecpient 
than  the  retrograde  embolism  above  mentioned. 

In  serous  cavities  tumor  cells  may  be  disseminated  upon  the  surfaces 
of  the  peritoneum,  pleura,  and  pericardium  by  the  movements  of  the 
viscera.  Tumor  cells  may  also  be  transplanted  into  an  operation-wound 
49 


762  GENERAL   PART 

during  the  removal  of  malignant  growths  (inoculation  metastases  or 
recurrences) .  The  structure  of  the  secondary  growth  is  always  the  same 
as  that  of  the  primary  tumor. 

The  formation  of  metastatic  growths  is  peculiar  to  tumors  with  an 
infiltrating  growth.  Tumors  with  an  expansive  growth  do  not  invade 
lymphatic  and  blood  vessels.  According  to  Ribbert,  the  clinically  sig- 
nificant but  not  sharp  division  of  tumors  into  the  benign  and  malignant 
is  based  upon  this  difference  in  growth,  and  not  alone  upon  the  char- 
acteristics of  the  tumor  cells.  Benign  tumors,  as  a  rule,  grow  sloAvly 
by  expansion  without  forming  metastases,  and  becomes  dangerous  only 
when  they  attain  great  size  or  interfere  with  the  function  of  some  of 
the  important  organs.  Malignant  tumors  form  metastatic  growths  giv- 
ing rise  to  regional  or  general  metastatic  growths,  and  as  they  infiltrate 
tissues  they  destroy  the  tissues  or  organs  involved.  The  more  closely 
the  cells  composing  a  tumor  approach  an  embryonal  type,  the  more 
rapid  the  growth  of  the  tumor  and  the  more  frequent  the  infiltrating 
growth  will  ])e. 

General  Constitutional  Effects  of  Tumors. — Tumors  may  produce  gen- 
eral constitutional  effects  which  consist  most  frecjuently  of  a  marked 
falling  off  in  the  nutrition  of  the  body — the  so-called  cachexia  of  tumors. 
This  cachexia  is  most  pronounced  in  malignant  tumors  when  accom- 
panied by  metastatic  growths,  but  may  also  occur  in  benign  growths  if 
they  are  multiple  (e.  g.,  multiple  lipomas)  or  if  they  attain  an  extraor- 
dinary size  (e.  g.,  fibromyoma  of  the  uterus,  large  fibrolipoma  of  the 
skin).  There  are  a  number  of  different  causes  of  cachexia,  such  as 
interference  with  the  function  of  the  viscus  involved,  interference  with 
the  general  functional  activity  and  nutrition  of  the  body,  pain,  loss 
of  sleep,  and  a  number  of  other  things.  Fever  and  the  absorption  of 
the  products  of  decomposition  from  the  tumor  and  of  putrefactive 
products  from  ulcerated  tumors  are  important  factors  in  causing  ca- 
chexia. Finally,  regressive  changes  in  a  tumor  may  give  rise  to  danger- 
ous com])lieatioiis,  such  as  aspiration  pneumonia  in  carcinoma  of  the 
mouth  or  peritonitis  after  perforation  of  a  carcinoma  of  the  stomach. 


CHAPTER    IV 

THE   GENERATj    DIAONORTS   OP    TUMORS 

'I' I  IK  diagnosis  of  a  tumor — that  is,  determining  whether  the  lesion 
is  a  tnif  tinnor  (differentiating  it  from  hyperplasias,  inflammatory  infil- 
1r;i1ions,  infcictious  granulomas  and  cysts)  and  determining  the  character 
of  llic  tumor — is  ])ased  upon  the  following: 


THE   GENERAL    DIACLNOSIS   OF   TUMORS  7G3 

I.  The  previous  and  present  history.  The  time  at  which  the  tumor 
began  to  develop,  the  determining  cause,  the  mode  of  growth,  and  the 
way  in  which  the  tumor  has  extended.  The  local  and  general  subjective 
symptoms  are  also  of  importance. 

II.  Upon  the  physical  findings  (A)  the  local,  (B)  the  general,  com- 
bined with  (C)  consideration  of  what  varieties  of  tumors  are  most  fre- 
quent in  the  area  or  organ  involved,  and  (D)  special  diagnostic  methods. 

A.  In   the   local   examination   the   position   and   peculiarities  of  the 
tumor  should  first  be  determined  by  inspection  and  palpation. 
Inspection  should  determine : 

1.  The  position  and  extent  of  the  tumor  in  relation  to  anatomical 
structures  (region  of  the  body,  contour  of  the  bone,  muscles,  tendons)  ; 

2.  The  form  (round,  oval,  irregular,  flat,  hemispherical,  nodular, 
pedunculated,  fungous,  cauliflowerlike,  papillary)  ; 

3.  The  size  (compared  Avith  well-known  objects  such  as  a  pea,  cherry, 
walnut,  hen's  egg,  child's  head,  or  accurate  measurements  of  its  trans- 
verse and  longitudinal  diameters)  ; 

4.  The  surface ; 

(a)  Covered  with  skin  or  mucous  membrane  (of  normal  appearance, 
permeated  with  dilated  vessels,  hyperamiic,  pigmented,  tense  and  shin- 
ing, transparent)  ; 

(&)  Sloughing,  ulcerated  (secreting,  bleeding  slightly,  covered  with 
crusts)  ; 

(0  Edges  of  the  ulcer  (forming  an  elevated  wall  or  flat,  sharply  cut, 
excavated,  or  eroded,  firmly  attached  to  underlying  tissues  or  under- 
mined, hard,  or  soft)  ; 

(n)  Floor  of  the  ulcer  (flat,  depressed,  craterlike,  or  filled  with 
growths,  necrotic,  uneven,  smooth,  or  fissured)  ; 

(Hi)  Surrounding  tissue  (normal,  raised  by  tumor  masses  or  invaded 
by  secondary  nodules)  ; 

(iv)  The  margins  (sharply  defined  or  indistinct,  circumscribed,  or 
diffuse). 

Palpation  should  determine : 

1.  The  relation  of  the  tumor  to  the  tissues  covering  it  (whether  the 
skin  covering  it  may  be  raised  in  folds  as  the  healthy  surrounding  skin, 
whether  the  skin  or  mucous  membrane  covering  the  tumor  can  be  dis- 
placed over  it,  whether  muscle  lies  between  the  skin  and  the  tumor. 
The  latter  is  to  be  determined  by  lifting  the  muscle  up — for  example, 
by  lifting  the  sterno-cleido-mastoid — or  by  testing  the  function  of  the 
muscle — for  exam])le,  by  testing  the  rigidity  of  the  al)doiiiinal  nmscles, 
by  elevation  of  the  arm  to  prove  whether  a  tumor  is  beneatli  the  deltoid). 

2.  The  characteristics  of  the  surface  of  the  tumor.  It  may  be  de- 
termined when  the  examination  is  made  concerning  the  displaceability 


764  GENERAL   PART 

of  the  tissues  covering  the  tumor  whether  its  surface  is  fiat  and  smooth, 
nodular,  lobulated,  or  irregular. 

3.  The  boundaries  of  a  tumor,  whether  they  are  distinct  or  indis- 
tinct, whether  sharply  defined  against  the  surrounding  tissues  or  whether 
they  disappear  indistinctly  into  the  deeper  parts— for  example,  below 
the  jaw,  at  the  mastoid  process — or  gradually  fuse  with  the  normal 
tissue. 

4.  The  position  of  the  tumor  and  its  anatomical  relations  (after  pal- 
pation of  adjacent  tendons,  muscles,  bones,  and  viscera). 

5.  The  relation  of  the  tumor  to  surrounding  and  subjacent  tissues 
(whether  it  can  be  moved  here  and  there  with  the  skin  and  soft  tissues, 
or  is  situated  deeply  upon  bone,  or  is  firmly  attached  to  tendons  or 
fascia ;  whether  it  moves  with  tendons,  muscles,  or  with  the  liver  during 
re,spiration). 

6.  The  consistency  of  the  tumor.  The  most  important  characteristic 
to  be  determined  is  whether  the  tumor  is  soft  or  hard. 

(a)  Only  the  experienced,  not  the  beginner,  can  detect  the  finer  dif- 
ferences, such  as  the  difference  between  the  hardness  of  cartilage  and 
bone,  and  betM^een  the  elastic  consistency  of  a  lipoma,  and  the  sensation 
imparted  by  a  soft  or  hard  fibroma. 

(b)  Fluctuation.  Hard  as  well  as  soft  tumors  may  fluctuate,  de- 
pending upon  whether  the  capsule  surrounding  the  fluid  or  liquefied 
masses  of  tumor  tissue  is  tense  or  relaxed.  A  hard,  fluctuating  tumor 
is  elastic.  In  soft  tumors  the  capsule  must  be  made  tense  by  pressure 
before  fluctuation  can  be  elicited. 

In  firmly  attached  or  slightly  movable  tumors  fluctuation  is  elicited 
in  the  same  way  as  in  abscesses.  The  index  finger  of  each  hand  should 
be  placed  upon  the  tumor  opposite  each  other,  first  at  a  small,  later 
at  a  greater,  distance  from  each  other.  The  fingers  should  be  laid  fiat 
upon  the  tumor,  and  only  in  examining  soft  tumors  should  any  great 
amount  of  pressure  be  exerted.  The  left  index  finger  (inactive  finger) 
is  then  held  quiet  and  motionless,  while  pressure  is  made  with  the  right 
(active  finger)  which  is  then  quickly  removed.  The  inactive  finger  will 
be  elevated  by  the  displaced  fluid  if  the  tumor  fluctuates. 

If  the  tumor  is  movable  it  is  best  to  grasp  it  between  the  index 
finger  and  thumb  of  each  hand.  If  pressure  is  then  made  with  both 
fingers  of  the  right  hand,  those  of  the  left  will  be  raised  if  fluid  is 
present. 

Sonic  1uni()i-s  (lipoma,  myxoma)  very  frequently  impart  the  sensa- 
ti(tii  ol"  iii(lisliM(;t  oi"  pseudo-fluctuation.  [Mistakes  are  not  infrequently 
iii.nic  even  l»y  cxpei'ts  in  determining  fluctuation.  I  myself  have  made 
I  lie  diagnosis  of  (hiid  in  a  case  of  fatty  tumor  in  the  infraspinous  fossa 
covered  by  tln'  infraspinatus  muscle.] 


THE   GENERAL   DIA(JN(JS1S   OF   TUMORS  765 

(r)  The  condition  found  in  dermoid  cysts  and  the  so-caUed  fu'cal 
tumors  (hard  fa'cal  masses),  in  whicli  the  depression  made  by  the  linj;er 
remains  and  only  tlisappears  when  pi-essure  is  made  upon  the  opposite 
side  of  the  tumor,  is  spoken  of  as  a  doughij  or  kneadahle  consistency. 

(d)  Pulsation  is  best  elicited  by  placing  the  hand  flat  ui)on  the 
tumor  without  exerting  pressure  (in  certain  haemangiomas  in  the  same 
way  as  in  aneurysms).  If  pressure  is  made  upon  the  principal  artery 
supplying  the  tumor,  pulsations  cease. 

(c)  A  tumor  is  spoken  of  as  compressible  when  it  diminishes  in  size 
under  pressure  and  enlarges  again  when  the  pressure  is  removed  (haem- 
angiomas and  lymphangiomas). 

(/)  Thrills  are  often  felt  in  pulsating  tumors  when  the  hand  is 
placed  upon  them  (vide  hydatid  fremitus  in  echinocoecus  cysts). 

(g)  Tumors  covered  by  a  thin  shell  of  bone,  when  palpated,  impart 
a  parchmentlike  sensation  or  crepitation. 

B.  The  general  examination  begins  with: 

1.  The  palpation  of  neighboring  lymph  nodes,  which  in  many  malig- 
nant tumors  are  enlarged  and  indurated,  then  follows : 

2.  The  examination  of  other  similar  growths,  if  present  (multiple 
tumors),  and  the  search  for  metastatic  growths  of  the  skin,  large  viscera, 
and  bones  (by  percussion  or  palpation). 

3.  The  special  examination  of  different  viscera  and  systems;  for  ex- 
ample, examination  of  the  urine  (for  albumin,  blood,  also  for  sugar  in 
supposed  pancreatic  tumor),  of  the  faeces  (for  blood,  and  mucus  in 
tumors  of  the  int(^stine),  of  the  gastric  juice  (in  tumors  of  the  stomach), 
of  the  function  of  the  kidneys  (the  solids  of  the  urine  are  estimated  by 
determining  the  freezing  points  of  the  urine  discharged  from  each  kid- 
ney), of  the  nervous  functions  (in  supposed  tumors  of  the  brain,  spinal 
cord,  and  peripheral  nerves),  of  the  blood  (to  determine  the  relative 
proportion  of  the  cells  in  diseases  of  the  blood-forming  organs,  the 
spleen,  lymph  glands,  and  bone  marrow). 

4.  The  critical  examination  of  the  general  condition  (cardiac  func- 
tion, anaemia,  digestion,  physical  and  mental  characteristics). 

C.  What  tumors  or  tumorlike  formations  occur  most  frequently  in 
the  area  or  organ  involved?  The  answer  to  this  question  often  makes  a 
definite  diagnosis  possible,  even  after  the  results  of  a  most  accurate 
examination  have  been  insufficient.  A  few  examples  will  render  this 
statement  clear.  . 

A  hard,  indistinctly  fluctuating,  round  tumor  which  is  slightly  mov- 
able upon  the  subjacent  tissues  and  has  no  connection  with  tendons  is 
situated  just  beneath  the  skin  in  the  palm  of  the  hand.  A  tumor  with 
similar  characteristics  situated  about  the  eye  would  be  diagnosed  at  once 
as  a  dermoid  cyst,  as  they  frequently  occur  here.     Not  so,  however,  in 


'66 


GENERAL   PART 


the  palm  of  the  hand.    Dermoid  eysts  do  not  occur  here,  while  epithelial 
cysts  (which  never  occur  about  the  eye)  do. 

In  considering  the  diagnosis  of  some  tumors,  their  connection  with  a 
nerve  may  be  definitely  established.  The  characteristics  of  the  tumor 
alone,  which  is  round,  of  average  hardness,  and  not  adherent  to  the  skin 
or  underlying  tissues,  Avill  suggest  the  variety.  The  few  varieties  of  the 
tumors,  however,  which  develop  upon  the  peripheral  nerves  limit  the 
differential  diagnosis  to  a  few  new  growths,  and  one  has  only  to  deter- 
mine whether  the  tumor  has  grown  slowly  or  rapidly  to  decide  whether 
it  is  a  fibroma  or  sarcoma. 

In  making  the  diagnosis  of  the  character  of  a  tumor  of  the  breast, 
the  position  is  very  important.     A  number  of  tumors  and  tumorlike 

hyperplasias  develop  in  the  breast 
do  not  occur  in  other  parts 
body.     A  lobulated,  nodu- 
)ft  tumor,  l.ying  beneath  nor- 
kin    and    displaceable    upon 
iderlying  tissue  is  not  to  be 
losed,  as  it  might  be  in  the 
as  a  lipoma.     The  relation 
tumor  to  the  breast  must 
be    determined.      Often    the 
entire  breast  or  parts  of 
it  may  be  hypertrophied 
and    cystic    (mastitis 
chronica  cystica),  a  con- 
dition which  might  easily 
be  mistaken  for  a  subcu- 
taneous lipoma. 

Tumors  of  similar 

characteristics  occur  even 

i|  ^Hf  '^V       "^   ^^^^   male   breast   and 

0  ig     J^B  '-^m        surrounding    tissues.      A 

\  "'^^^B  "^B       similar  lesion  of  the  male 

breast   may  be  a  tumor 
or  a  condition  known  as 
gyna^comastia,    in    Avhich 
the    breast    undergoes    a 
hyperplasia  of  all  its  com- 
ponent parts  (which  may 
<'V('ii  he  unilateral)   and  resembles  the  female  breast   (Fig.  282).     Car- 
cinoma of  the  breast  has  some  special  characteristics,  such  as  very  evi- 
dent infill i-a1  ion  of  the  gland,  retraction  of  the  nipple,  etc.     Frequently 


I'll).  282.- 


-Gyn.kcomastia  (Kigmt  Side),  Malk  Patient 
KuiiiTEEN  Ykahs  Old. 


THE   GENERAL   DIAGNOSIS  OF   TUMORS  767 

a  definite  diagnosis  of  carcinoma  of  the  breast  can  be  made  nuich  earlier 
than  that  of  carcinoma  of  other  parts. 

Elyelogenous  and  periosteal  sarcomas,  chondromas,  and  osteomas  are 
the  most  common  tumors  of  bone.  In  spite  of  this  a  flat  or  nodnlar, 
resistant,  not  sharply  defined  tumor  which  is  attached  to  the  bone,  is 
covered  by  normal  skin,  and  has  grown  rapidly  cannot  be  diagnosed  as  a 
sarcoma  without  considering  some  other  lesions.  One  should  think  of  the 
enlargement  associated  with  chronic  suppurative  and  tuberculous  osteo- 
myelitis, and  especially  of  a  periosteal  gumma,  which  occurs  most  com- 
monly upon  the  diaphysis  of  the  tibia,  and  search  for  other  evidences 
or  remains  of  the  infectious  diseases  above  mentioned  should  be  made. 

Any  number  of  such  examples  might  be  cited.  Those  already  men- 
tioned show  conclusively  that  an  accurate  knowledge  of  special  pathol- 
ogy, vast  experience  in  diagnosis,  the  ability  to  weigh  possibilities,  and 
an  extended  clinical  experience  are  required  before  the  diagnosis  of 
tumors  can  be  made  correctly  and  with  certainty. 

Even  the  most  expert  diagnosticians  are  frequently  unable  to  make 
a  positive  diagnosis,  being  unable  to  decide  between  a  number  of  pos- 
sibilities. 

D.  Special  diagnostic  aids.  Aspiration,  exploratory  incision  and  ex- 
cision with  microscopical  examination.  X-ray  pictures  and  special  meth- 
ods in  abdominal  tumors  are  diagnostic  aids. 

1.  Puncture  and  aspiration  of  a  swelling  is  important  when  it  is  dif- 
ficult or  impossible  to  determine  its  consistency  (indistinct  fluctuation). 
By  inserting  a  needle  or  canula,  it  is  possible  to  determine  whether 
fluid  is  present  or  not,  and  if  present  the  character  of  the  same  (serous, 
ha?morrhagic,  purulent,  mucoid,  or  fluid  from  echinococcus  cysts). 

2.  The  exploratory  incision  is  sufficient  in  many  cases  to  enable  the 
surgeon  to  make  a  definite  diagnosis  as  to  the  character  of  the  tumor 
by  the  macroscopic  appearance  of  its  cut  surface  (e.  g.,  lipoma  or  sar- 
coma, fibroma  or  carcinoma  of  the  mammary  gland).  The  harpooning  of 
pieces  of  tumor  tissue,  which  was  employed  extensively  in  preantiseptic 
times,  is  no  longer  practiced.  Harpooning  consisted  of  inserting  an 
instrument  provided  in  barbs  (similar  to  a  harpoon)  and  removing 
small  pieces  of  tissue  from  the  tumor,  which  could  be  used  for  micro- 
scopic examination   (^Nliddeldorpf 's  harpoon). 

Excision  of  pieces  of  tissue  for  microscopic  examination  is  often 
resorted  to.  Small  pieces  of  tissue  are  removed  for  microscopic  exami- 
nation in  cases  in  Avhich  it  is  probable  that  a  tumor  is  malignant,  but  the 
symptoms  are  not  pronounced  enough  to  make  a  positive  diagnosis 
possible.  It  is  of  most  value  when  tumors  are  first  beginning  to  develop 
(e.  g.,  to  diagnose  between  psoriasis,  syphilis,  and  beginning  carcinoma 
of  the  tongue,  between  carcinoma  and  papilloma  of  the  larynx,  in  sus- 


768  GENERAL  PART 

pected  carcinoma  of  the  uterus).  A  small  wedge-shaped  piece  of  tissue 
is  removed  from  the  surface  of  the  tumor,  and  the  resulting  wound  is 
touched  with  a  thermocautery  to  control  the  haemorrhage.  In  tumors 
of  the  larynx  a  good  view  of  the  tumor  should  first  be  had  with  the 
laryngoscope  before  the  tissue  is  removed  with  forceps,  in  order  to  be 
certain  that  the  tissue  is  removed  from  the  tumor  and  not  from  the 
diseased  area  adjacent  to  it. 

In  many  cases  pieces  which  are  separated  and  cast  off  from  the 
tumor  may  be  used  for  examination  (e.  g.,  tissue  expectorated  in  tumors 
of  the  mediastinum  and  lungs,  vomited  in  carcinoma  of  the  stomach, 
passed  in  the  urine  in  tumors  of  the  bladder,  in  the  fajces  in  carcinoma 
of  the  rectum). 

X-ray  pictures  are  of  value  in  many  cases.  Hard  tumors  and  those 
consisting  of  bone  (osteoma,  osteosarcoma),  or  containing  pieces  of  bone 
(teratoma)  may  often  be  recognized  in  pictures  by  their  nodular  form 
and  differentiated  from  inflammatory  infiltrations  and  hyperostoses. 
The  appearance  of  the  bone  from  which  the  tumor  develops  depends 
upon  whether  or  not  it  is  destroyed  by  the  new  growth.  Exostoses  are 
attached  by  broad  or  thin  pedicles  to  the  surface  of  the  bone.  A  perios- 
teal sarcoma  surrounds  the  bone  which  in  the  beginning  at  least  is  still 
normal,  the  contour  of  which  can  be  seen  through  the  shadow  of  the 
tumor.  Small  central  tumors  can  be  differentiated  from  inflammatory 
processes  only  when  the  cortical  layer  of  bone  covering  them  has  become 
thinned.  As  a  rule,  bone  surrounding  inflammatory  processes  becomes 
thickened  and  sclerotic.  Often  it  can  be  seen  that  the  tumor  has  rup- 
tured through  the  thinned  and  expanded  parts  of  the  cortex  at  a  num- 
ber of  points.  Tumors  of  the  mediastinum  can  often  be  diagnosed  by 
an  X-ray  examination. 

In  the  examination  of  abdominal  tumors  a  number  of  different  diag- 
nostic methods  arc  employed  to  determine  the  position  of  the  tumor 
and  its  relation  to  neighboring  organs.  For  example,  the  stomach  may 
be  distended  with  an  effervescing  powder,  the  colon  with  air  or  water 
in  order  to  dctcn-mine  the  relation  of  the  tumor  to  these  organs,  whether 
it  is  in  front  or  bcliind  oi-  whether  the  tumor  changes  its  position  as 
the  organs  are  distended. 

EXAMPLE   OF   THE   METHOD   EMPLOYED   IN   MAKING  THE 
DIAGNOSIS   OF   A   TUMOR 

LIPOMA 

I.  Anamnesis:  Symmetrienl,  gradual  growth  for  a  number  of  years, 
no  cause,  no  trouble,  only  discomfort  because  of  size,  general  condition 
of  patient  unchanged. 


THE   GENERAL   DIAGNOSIS   OF   TUMORS  769 

II.  Status:   (A)   The  local  examination  by  inspection: 
1.  Position  and  extent.     A  tnmor  is  present  upon  the. back  of  the 
patient,  in  the  right  scapular  region,  covering  almost  the  entire  bone. 

•  2.  Its  form  is  almost  ov;)l ;  in  profile  hemispherical,  with  an  indis- 
tinct tonguelike  process  upon  the  medial  side. 

3.  Its  size  is  a  little  larger  than  the  head  of  a  newborn  child. 

4.  Its  surface  is  covered  by  normal  skin. 

5.  Its  boundaries  are  sharp  and  distinct  except  along  the  lower 
part. 

By  palpation : 

1.  The  skin  may  be  raised  in  folds  from  the  surface  of  the  tumor, 
but  the  skin  is  thinner  than  that  of  the  area  adjacent.  [In  doing  this 
an  irregular  wrinkling  is  produced  by  the  trabeculip  of  connective  tissue 
which  divide  the  lobules  of  the  tumor.]  In  some  areas  the  skin  covering 
the  tumor  is  less  movable. 

2.  The  surface  of  the  tumor  is  smooth  throughout.  At  the  margins 
distinct,  round  projections  may  be  felt,  and  upon  the  medial  side  a 
large  process.     Both  may  be  made  visible  by  rendering  the  skin  tense. 

3.  The  boundaries  of  the  tumor  are  sharply  defined  and  distinct  from 
the  surrounding  structures  except  along  the  lower  margin. 

4.  The  position  of  the  tumor  corresponds  to  the  right  scapula.  Its 
lower  part  disappears  beneath  the  latissimus  dorsi,  the  border  of  which 
may  be  distinctly  palpated. 

If  the  muscle  is  made  to  contract  by  pressing  the  arm  against  the 
side  of  the  chest,  the  lower  part  of  the  tumor  becomes  harder  and  its 
lower  boundary  still  more  indistinct. 

5.  The  tumor  is  but  loosely  attached  to  underlying  structures  (fas- 
cia), as  it  can  be  easily  displaced  in  all  directions. 

6.  Its  consistency  is  soft.  If  the  tumor  is  grasped  with  four  fingers, 
indistinct  or  pseudo-fluctuation  may  be  elicited. 

(B)  The  general  examination  reveals  no  enlargement  of  the  regional 
lymph  nodes.  Another  tumor  aliout  as  large  as  a  walnut  with  similar 
characteristics  is  situated  upon  the  outer  side  of  the  left  thigh.  The 
general  appearance  of  the  patient  is  good. 

(C)  The  part  involved  (the  back  in  the  region  of  tlie  shoulder)  is  a 
common  site  for  subcutaneous  lipomas.  The  findings  correspond  to  such 
a  tumor.  Other  tumors  occurring  in  this  region,  such  as  a  sarcoma, 
may  be  excluded  because  of  the  slow  growth ;  atheromas  because  of  their 
round  form  and  small  size. 

(D)  Special  diagnostic  aids,  such  as  puncture  and  aspiration,  are 
not  necessary. 

Diagnosis :  Circumscribed  subcutaneous  lipomas  over  the  right  scap- 
ula and  on  outer  surfaces  of  left  thigh. 


770  GENERAL   PART 


SARCOMA 


I.  Anamnesis:  For  one  half  year  an  enlargement  in  the  region  of 
the  right  scapula  has  been  noticed.  For  two  months  the  growth  has 
been  rapid,  accompanied  by  pain  and  limitation  of  motion  of  the  arm. 
For  two  weeks  marked  general  weakness,  attacks  of  coughing,  and  pain 
upon  breathing  in  left  side  of  thorax  have  been  present. 

II.  Status:  (A)  Local  examination  by  inspection: 

1.  Size  and  extent.  A  tumor  in  the  region  of  the  right  scapula,  in- 
volving the  area  below  the  spine,  extending  about  4  cm.  below  it. 

2.  Its  form  is  that  of  a  round,  flat  swelling. 

3.  Its  size  corresponds  to  that  of  a  child's  head. 

4.  Its  surface  is  covered  in  the  upper  half  by  skin  which  appears 
normal,  while  that  covering  the  lower  half  is  traversed  by  dilated  veins. 

5.  The  boundaries  of  the  tumor  are  ill-defined. 
By  palpation : 

1.  The  relations  of  the  tumor  to  structures  covering  it  differ.  The 
skin  covering  the  upper  part  of  the  tumor  may  be  raised  in  folds,  and 
is  of  the  same  thickness  as  the  surrounding  skin.  In  the  lower  part 
the  skin  is  so  firmly  attached  to  the  surface  of  the  tumor  that  it  cannot 
be  raised  in  folds. 

2.  The  surface  of  the  tumor  is  smooth  with  superficial  furrows. 

3.  Its  boundaries  can  be  distinctly  made  out  in  the  lower  part  only. 

4.  The  position  of  the  tumor  corresponds  to  the  right  scapula.  Above 
the  boundary  becomes  indistinct  at  the  spine  of  the  scapula;  medially 
and  laterally  it  fuses  with  the  neighboring  muscles;  below  it  extends 
two  fingers'  breadth  beyond  the  angle  of  the  scapula.  There  is  no 
nniscle  between  the  tumor  and  the  skin,  at  least  muscle  cannot  be  recog- 
nized during  active  movements.  The  tumor  is  attached  to  the  scapula, 
following  its  movements. 

5.  It  is  also  firmly  attached  to  the  underlying  bone,  as  it  cannot  be 
displaced  over  the  scapula. 

f).  The  consistency  of  the  tumor  is  hard,  and  only  at  a  small  point 
ill  llic  lower  part  where  it  is  attached  to  the  skin  can  fluctuation  be 
elicited. 

(B)  The  geiHMcil  examination  reveals  no  enlargement  of  the  axillary 
lymph  nodes.  Similar  growths  are  not  present  upon  any  other  part 
of  the  l)ody.  A  general  physical  examination  reveals  some  involvement 
of  the  left  lung.  There  is  a  left  pleuritic  efl'usion  and  the  expectoration 
is  bloody.  Aspiration  reveals  an  effusion  which  is  bloody  in  character. 
The  sallow  appearance  of  llic  patient  and  the  grcnit  weakness  are  striking. 

(C)  The  area  involved  is  the  favorite  site  foi- -lipomas  (see  previous 
example),  but  a  lij)oma  does  not  become  attached  to  bone.     Exostoses, 


THE   GENERAL   DIAGNOSIS  OF  TUMORS  771 

encliondronias,  and  .sarcomas  are  tlie  most  common  of  the  oilier  varieties 
of  tumors  developing  on  the  scapula.  The  indistinct  boundaries  and 
rapid  growth  speak  for  a  sarcoma,  and  there  are  no  findings  which  sug- 
gest that  the  tumor  is  not  of  this  character.  The  involvement  of  the 
lung  is  to  be  regarded  as  metastatic  in  character.  ITamiorrhagic  pleural 
exudates  are  freqnently  associated  with  tumors  of  the  lung. 

(D)  Aspiration  of  the  small  fluctuating  area  reveals  dark  blood. 
The  X-ray  pictures  show  the  indistinct  shadows  of  the  scapula. 

Diagnosis :  Cystic  osteosarcoma  of  the  right  scapula  with  metastatic 
growths  in  the  lung. 

TUMOR    OF    THE    BREAST 

I.  Anamnesis :  For  six  months  a  woman  forty-five  j'ears  of  age  has 
noticed  a  hard  nodule  in  the  left  breast.  This  was  first  noted  after  a 
blow.  For  some  weeks  the  skin  covering  the  rapidly  growing  mass  has 
been  discolored.  A  short  time  before  the  present  examination  the  skin 
covering  the  mass  ulcerated  and  a  ha?morrhagic  fluid  was  discharged. 
The  open  area  has  enlarged  rapidly  and  bleeds  profusely  at  times. 
Severe  pains  radiate  from  the  mass  and  a  foul-smelling  secretion  is 
poured  out.  The  strength  of  the  patient  has  been  considerably  reduced 
since  the  lesion  was  first  noticed. 

II.  Status:   (A)   Local  examination  by  inspection: 

1.  Size  and  extent.  The  left  breast  is  about  twice  its  normal  size, 
and  upon  the  outer  side  the  new  growth  extends  beyond  the  limits  of 
the  breast. 

2.  The  form  of  the  enlarged  breast  is  that  of  an  irregular,  nodular 
hemisphere. 

3.  Its  size  corresponds  to  that  of  a  large  normal  mammary  gland. 

4.  Its  surface : 

(a)  In  the  upper  half  is  covered  by  normal  skin.  The  nipple  is 
greatly  retracted.  The  skin  to  the  medial  side  of  the  nipple,  covering 
the  nodular  growth,  is  of  a  bluish  red  color. 

(&)  To  the  outer  side  of  the  nipple  in  the  lower  half  of  the  gland 
is  an  ulcer  the  size  of  a  dollar  which  is  surrounded  by  a  l)luish  red  zone. 
It  pours  out  a  foul-smelling,  serolupmorrhagic  secretion,  and  is  covered 
with  crusts  and  bleeds  at  some  points. 

(t)  The  edges  of  the  ulcer  are  raised  and  wall-like,  liai-d,  iriH'gular, 
and  at  some  points  undermined. 

(m)  The  floor  of  the  ulcer  is  depressed  and  craterlike,  fissured  and 
nodular  only  near  the  edges. 

(m)   The  surrounding  tissues  are  raised  by  tumor  masses. 

5.  The  boundaries  of  the  tumor  are  not  distinct  and  cannot  be  sharply 
defined. 


772  GENERAL  PART 

By  palpation : 

1.  The  relation  of  the  tnmor  to  the  skin  covering  it  differs.  In  the 
upper  half  the  skin  may  be  raised  in  folds,  while  in  the  lower  medial 
quadrant,  adjacent  to  the  ulcer  and  nipple,  it  is  intimately  attached  to 
the  nodular  tumor.     The  retracted  nipple  cannot  be  drawn  out. 

2.  The  surface  of  the  tumor  is  irregular  and  nodular. 

3.  The  boundaries  of  the  tumor  are  sharp  and  well  defined  upon  the 
outer  side  only.  The  upper  boundary  is  not  sharply  defined  against  the 
normal  breast;  below  the  tumor  becomes  fused  with  the  deeper  struc- 
tures. 

4.  The  tumor  is  situated  in  the  left  breast. 

5.  It  is  firmly  attached  to  the  underlying  tissue,  as  it  cannot  be 
moved  upon  the  thorax,  and  remains  stationary  when  the  pectoral  is 
major  contracts. 

6.  Its  consistency  is  everywhere  hard. 

(B)  The  general  examination  reveals  greatly  enlarged,  indurated 
lymph  nodes  in  the  left  axillary  and  supraclavicular  fossae.  There  are 
no  secondary  nodules  in  the  structures  adjacent  to  the  tumor.  Nothing 
abnormal  can  be  found  in  the  viscera  (especially  the  lungs  and  liver). 
The  patient  is  anaemic  and  the  general  condition  is  bad. 

(C)  In  making  a  diagnosis  in  this  case  it  is  important  to  remember 
that  tumors  in  the  part  involved — the  female  breast — are  very  common. 
Benign  growths,  such  as  fibro-adenomas  and  lipomas,  hypertrophy  of 
the  breast,  and  interstitial  mastitis  as  well  need  not  be  considered  in 
making  a  diagnosis  in  this  case.  The  rapid  growth,  ulceration,  and 
involvement  of  lymph  nodes  make  the  diagnosis  of  a  malignant  growth 
positive.  The  indurated  lymph  nodes,  the  hardness  of  the  tumor,  and 
the  characteristic  form  of  the  ulcer  speak  for  carcinoma,  which  is  com- 
mon in  the  breasts  of  women  over  forty  years  of  age. 

(D)  The  microscopic  examination  of  a  piece  of  tissue  which  sloughed 
oiiP  revealed  a  scirrhous  carcinoma. 

Diagnosis :  Carcinoma  of  the  left  mammary  gland. 


CHAPTER    V 

GENEHATj    DISCTTSRION    OF    THE    TREATMENT    OP    TUMORS 

Thorough  oix'i-ative  removal  of  all  parts  of  a  tumor  is  the  most  cer- 
tain therapeutic  measure.  It  is  usually  indicated  in  the  treatment  of 
all  timiors,  excej)tiiig,  of  course,  benign  tumors  giving  rise  to  no  trouble 
wlii'ic  llic  opei-ation   would  be  severe  or  mutilating  and  the  cosmetic 


\ 


GENERAL  DISCUSSION   OF  THE  TREATMENT  OF  TUMORS       773 

results  bad.  Small  tiiinors  of  the  skin  may  lie  excised  by  an  oval  ex- 
section  of  the  skin,  and  the  resulting  wound  sutured.  In  the  face, 
plastic  operations  are  often  required  to  close  the  defect  following  the 
removal  of  tumors  of  the  skin,  as  immediate  closure  without  such  a 
procedure  often  leads  to  distortion  of  the  parts  and  deformity. 

The  operative  removal  of  malignant  tumors  is  possible  only  when 
the  diagnosis  is  made  early  and  the  growth  is  just  beginning.  Even 
then  the  excision  must  be  carried  into  healthy  tissues,  especially  in 
cases  of  carcinoma,  and  the  neighboring  lymph  nodes  must  be  exposed 
and  removed  even  when  there  are  no  macroscopic  changes. 

A  malignant  tumor  may  be  inoperable:  (1)  Because  of  the  size  of 
and  extent  of  the  primary  growth;  (2)  because  of  metastases  into  the 
lymph  nodes;  (3)  because  of  other  metastases  (disseminated,  lymph- 
ogenous nodules  in  the  surrounding  skin  and  lia?matogenous  metas- 
tases). 

Inoperable  Tumors. — For  example,  a  carcinoma  of  the  breast  is  inop- 
erable if  the  tumor  is  firmly  attached  to  the  chest  wall,  or,  even  if  the 
tumor  is  small,  when  the  supraclavicular  as  well  as  the  axillary  lymph 
nodes  are  involved ;  when  there  are  small,  disseminated  nodules  in  the 
surrounding  skin,  or  metastases  in  the  viscera  (lung,  liver)  or  in  the 
bones  (neck  of  the  femur  with  spontaneous  fracture,  in  the  vertebra 
leading  to  pain,  kyphosis,  etc.). 

Cauterization  and  its  Indications, — Cauterization  (with  a  thermo- 
cautery or  caustics,  in  pedunculated  fibromas  of  the  mucous  membrane 
with  the  loop  of  a  galvano-cautery)  is  to  be  recommended  for  the  re- 
moval of  small,  benign  tumors,  such  as  warts  and  pedunculated  fibromas 
of  the  skin  and  mucous  membranes  only.  It  is  to  be  discarded  in  the 
treatment  of  other  forms  of  tumors,  as  the  removal  is  not  complete,  and 
M'hen  there  is  a  possibility  of  malignancy.  Experience  has  shown  that 
the  irritation  following  cauterization  hastens  considerably  the  growth  of 
malignant  tumors.  Besides,  hideous,  often  deforming,  scars  remain  after 
cauterization. 

Ligation. — The  ligation  of  the  pedicle  of  pedunculated  tumors 
(warts,  pendulous  fibroma)  is  performed  by  lay  people  and  physicians 
who  fear  the  knife.  The  object  of  ligation  is  to  produce  a  necrosis  and 
subsequent  sloughing  of  the  tumor.  The  great  disadvantage  of  this 
procedure  is  that  parts  of  the  tumor,  from  which  the  growth  recurs, 
often  remain.  The  operations  to  be  employed  in  the  treatment  of  dif- 
ferent varieties  of  tumors  are  descj-ibed  in  their  respective  chapters. 

Light  Therapy:  Indications  and  Contra-indications. — Light  therapy  is 
a  modern  method  of  treatment.  The  eft'oi'ts  which  have  been  made  to 
remove  tumors  by  bloodless  methods,  and  the  discovery  that  the  X-rays, 
radium,  and  Finsen  rays  produced  inflammatory  changes  in  the  skin 


774  GENERAL  PART 

often  resulting  in  necrosis,  led  to  a  number  of  experiments  dealing 
with  the  effect  of  the  above-mentioned  rays  upon  tumors.  X-rays  in 
particular  seem  to  have  some  special  action,  as  it  has  been  demonstrated 
that  warts,  telangiectases,  and  carcinomas  of  the  skin  which  have  been 
exposed  to  the  rays  often  disappear  completely.  This  is  apparently  due 
to  the  degeneration  of  the  tumor  cells  (von  INIikulicz  and  Fittig,  Pusey, 
Hyde,  Bevan,  Perthes,  von  Bruns). 

In  the  treatment  of  superficial  tumors  the  so-called  soft  (low  vacuum) 
tube  is  employed.  The  diseased  area  is  exposed,  the  tube  being  at  a 
distance  of  10  cm.,  from  five  to  fifteen  minutes,  some  days  intervening 
between  exposures,  or  from  five  to  ten  minutes  for  a  number  of  succes- 
sive days.  The  healthy  surrounding  skin  should  be  protected  by  a  lead 
plate  while  the  treatment  is  being  given.  If  the  tumor  is  deeply  situated 
a  hard  (high  vacuum)  tube  should  be  employed,  the  rays  from  which 
penetrate  more  deeply.  If  the  rays  have  the  proper  penetration  the 
bones,  when  looked  at  through  a  fluoroscope,  should  cast  a  gray,  not  a 
black  shadow.  According  to  our  present  knowledge,  the  treatment 
should  be  c(mtinued  only  until  an  erythema  of  the  normal  skin,  with 
or  without  vesicle  formation,  develops.  Usually  this  occurs  after  two 
Aveeks.  If  the  dosage  is  higher  (harder  tube  or  continued  for  a  longer 
time)  alterations  in  the  vessels  of  the  normal  skin  (degeneration  of  the 
intima  and  muscularis,  Gassmann)  which  often  lead  to  necrosis  develop, 
and  the  rays  are  then  no  longer  suited  for  the  treatment  of  tumors 
(Perthes).  Chronic  "  Roentgen-ray  ulcers,"  which  may  occasionally 
become  transformed  into  carcinomas,  may  develop  after  long  and  im- 
proper exposures. 

In  the  treatment  of  benign  tumors  a  trial  with  the  X-rays  is  always 
permissible.  In  the  treatment  of  malignant  tumors  the  X-rays  should 
be  considered  only  for  the  small,  flat  carcinomas  of  the  skin,  espe- 
cially those  occurring  upon  the  face,  which  pursue  a  chronic  course 
and  rarely  form  metastases.  It  should  be  kept  in  mind,  however,  that 
even  in  these  cases,  while  there  may  be  apparent  healing,  the  growth 
may  be  extending  more  deeply  beneath  the  scar,  so  that  soon  after 
superficial  healing  regressive  changes  may  occur,  leading  to  the  forma- 
tion of  a  deep  ulcer  which  may  even  penetrate  to  bone.  The  simplicity, 
rapidity,  and  safety  of  the  operative  treatment  are  in  marked  contrast 
to  the  slowness  and  uncertainty  of  this  method. 

X-ray  treatment  of  other  operable  malignant  tumors,  such  as  deep 
carcinomas  and  sarcomas,  should  be  discarded.  It  can  never  replace 
the  ()[)ei-ative  treatment,  as  the  destruction  and  absorption  are  limited 
to  tlie  snpci'fieiai  parts  of  the  tumor  and  occni-  })iit  slowly  during  the 
course  of  weeks  and  months.  In  the  treatment  of  malignant  tumors, 
delay  of  complete  i-emoval  merely  favors  the  formation  of  metastases. 


GENERAL   DISCUSSION   OF   THE   TREATMENT   OF   TUMORS       775 

For  example,  of  what  value  is  it  if  a  carcinoma  of  the  lip  heals  after 
a  number  of  exposures  to  the  X-rays  extending  over  a  number  of  months, 
and  in  the  meantime  the  regional  lymph  nodes  have  become  so  large 
and  so  firmly  attached  to  the  mandible  and  large  vessels  that  the  case 
is  no  longer  operable!  Such  cases  have  been  shown  b.y  specialists  in  skin 
diseases  to  demonstrate  "  the  good  results  obtained  by  this  new  method 
of  treatment."  The  dangers  of  metastases,  which  cannot  be  prevented 
by  the  X-rays,  demand  that  this  method  be  discarded  in  the  treatment 
of  malignant  tumors  which  are  still  operable. 

On  the  other  hand  the  X-rays  are  of  decided  value  in  the  treatment 
of  inoperable,  malignant  tumors.  Fre<iuently  such  tumors  have  been 
seen  to  decrease  in  size,  and  even  if  the  formation  of  metastases  and 
the  deeper  extension  of  the  growth  are  not  prevented,  the  apparent  im- 
provement of  the  local  ccmdition  is  of  inestimable  value  to  the  doomed 
patient. 

In  the  treatment  of  inoperable  tumors,  it  should  be  especially  empha- 
sized that  the  patient  should  not  be  deprived  of  the  hope  of  recovery. 
The  truth  as  to  the  nature  of  the  disease  should  be  concealed  from  the 
patient  whenever  it  is  possible.  But  when  the  surgeon  is  compelled, 
])ecause  of  family  relations  or  the  demands  of  the  patient,  to  depart 
from  this  rule,  he  should  explain  the  nature  of  the  lesion  in  a  serious, 
earnest  manner,  and  never  treat  it  as  a  trivial,  insignificant  matter. 

Local  Treatment. — The  objects  of  local  treatment  are  the  partial  de- 
struction of  the  tumor  and  healing  of  ulcerated  areas.  Partial  destruc- 
tion may  follow  the  X-ray  treatment,  the  parenchymatous  injection  of 
alcohol  and  zinc-chlorid  solutions  (twenty  to  fifty  per  cent).  [These 
parenchymatous  injections  may  produce  a  necrosis  of  parts  of  the  tumor 
or  a  proliferation  of  the  connective  tissue,  which  as  it  contracts  stran- 
gles, as  it  were,  the  epithelial  cells.]  Sometimes  apparent  improve- 
ment follows  the  internal  administration  of  arsenic  preparations  and  of 
the  iodid  of  potassium.  Ulcerated  surfaces  should  be  protected  from 
infection  (erysipelas,  putrefactive  phlegmon)  by  aseptic  dressings  and 
sterilization  of  the  surrounding  skin.  The  foul-smelling  discharge  may 
be  lessened  by  using  compresses  of  hydrogen  peroxid,  acetate  of  alumi- 
num, etc.  The  actual  cautery  and  caustics  (moist  compresses  of  from 
twenty  to  fifty  per  cent  zinc  chlorid  according  to  Czerny)  may  be  em- 
ployed for  the  same  purpose. 

Treatment  by  Coley's  Toxins. — Busch  (1866),  later  von  Bruns  and 
Biedert,  observed  that  occasionally  a  sarcoma  underwent  fatty  degen- 
eration, disappeared,  and  did  not  recur  after  an  attack  of  erysipelas. 
Carcinomas  may  even  become  smaller,  and  Fehleisen  reported  a  case 
in  which  a  carcinoma  subsided  after  an  attack  of  erysipelas  artificially 
produced.     Many  attempts  have  been  made  of  late,  especially  by  Coley, 


776  GENERAL   PART 

to  cure  malignant  growths  by  injections  of  sterile  streptococcic  cultures. 
[The  mixed  toxins  of  prodigiosus  and  streptococcus  introduced  by  Coley 
have  a  distinct  beneficial  effect  in  sarcomas,  and  should  be  employed  in 
all  inoperable  cases,  as  a  small  percentage  are  greatly  benefited  and  some 
are  even  cured  by  this  treatment.] 

Morphin. — Morphin  or  codein  should  be  given  for  the  pain  develop- 
ing Avithin  and  radiating  from  the  tumor.  In  many  cases  it  is  the  only 
drug  which  will  render  the  life  of  the  patient  bearable. 

If,  as  a  result  of  erosion  of  one  of  the  larger  vessels,  the  haemorrhage 
from  the  ulcerated  mass  is  severe,  all  the  methods  at  the  command  of  the 
surgeon  for  control  of  haemorrhage  should  be  employed. 

The  general  treatment  should  be  symptomatic.  Serum  treatment  up 
to  the  present  time  has  given  no  results.  Ehrlich's  investigations,  how- 
ever, have  demonstrated  what  lines  should  be  followed  in  this  work. 
By  inoculation  of  mice  with  mouse  carcinoma  of  low  virulence,  he  has 
rendered  them  inunune  against  mouse  carcinoma  of  high  virulence. 

[An  interesting  experiment  has  been  performed  by  Crile  and  Beebe, 
in  which  the  blood  of  dogs  with  a  rapidly  growing  sarcoma  was  re- 
Xjlaced  by  direct  transfusion  with  blood  from  sarcoma-immune  dogs, 
resulting  in  the  disappearance  of  the  tumors.] 

Literature. — Apolant.  Ueber  den  jetzigen  Stand  der  Krebsforschung.  Ther. 
d.  Gegenwart,  1906,  April. — Borst.  Die  Lelire  von  den  GeschwiUsten.  "Wiesbaden, 
1902. — V.  Bruns.  Krebsbehandlung  mit  Rontgenstrahlen.  Therap.  d.  Gegenwart, 
1904. — Cohnheim.  Vorlesungen  iiber  allgemeine  Pathologie.  Berlin,  1882. — Czerny. 
Warum  diirfen  wir  die  parisitare  Theorie  fiir  die  bosartigen  Geschwiilste  nicht  aufgeben? 
Beitr.  z.  klin.  Chir.,  Bd.  25,  1899,  p.  243; — Ueber  die  Behandlung  inoperabler  Krebse. 
Chir.  Kongr.-Verhandl.,  1900,  II,  p.  1; — Ueber  Heilversuche  bei  malignen  Geschwiilsten 
mit  Erysipcltoxinen.  Miinch.  med.  Wochenschr.,  1895,  p.  833. — Ehrlich.  Exper. 
Karzinonisfudien  an  Miiusen.  Zeitschr.  f.  artzl.  Fortbild.,  1906,  p.  205,  and  Arbeiten 
aus  deiii  K.  Inst.  f.  experim.  TherajMe.  Jena,  1906. — Exner.  Ueber  die  bisherigen 
DauorresuUato  nach  Radivimbehandlung  von  Karzinonien.  Deutsche  Zeitschr.  f. 
Chir.,  Bd.  75,  1904,  \^.  379. — F'tttlg.  Ueber  die  Behandlung  der  Karzinome  mit  Rontgen- 
strahlen. Beitr.  z.  klin.  Chir.,  Bd.  42,  1904,  p.  505. — Friedrich.  Heilversuche  mit 
Baktoriongiften  bei  inoperablen  bosartigen  Neubildungen.  Chir.  Kongr.-Verhandl., 
1S95,  II,  p.  312. — Gassmann.  Zur  Histologic  der  Rontgenulcera.  Fortschr.  a.  d. 
(U'h.  <1.  Riintgonstrahlen,  Bd.  2,  1898-99,  p.  199. — Geissler.  Die  Uebertragbarkeit 
der  Karzinouio.  Arch.  f.  klin.  Chir.,  Bd.  46,  1903,  p.  655. — Lowenthal.  Ueber  die 
(rauiiiaUscho  ICntstehung  der  Geschwiilste.  Ardi.  f.  klin.  Chir.,  Bd.  49,  1895,  p.  1. — 
Luliitrsrh.  Zur  Lohre  von  den  Geschwiilsten  vnid  Infektionskrankheiten.  Wiesbaden, 
\H'.)'.).—Lurrk(',  and  Zahn.  Chirurgie  der  Geschwiilste.  Deutsche  Chir.,  1896. — v. 
Milcidirz  and  Fill'u].  Ik'ber  eincn  mit  Rcintgenstrahlen  erfolgreich  behandelten  Fall 
von  Brus)driisonkrcbs.  Beitr.  z.  klin.  Chir.,  Bd.  37,  1903,  p.  676. — Perthes.  Ueber 
den  lOinfluHH  der  Riintgcnstrahlen  auf  epitheliale  Gewebe,  insbesondere  auf  das  Karzinom. 
Chir.  Kongr.-Verhandl.,  1903,  II,  p.  525; — Versuche  iiber  den  Einfluss  der  Rontgen- 
Hfr:ihlcn  urid  Radiumstrahlen  auf  die  Zellteilung.  Deutsche  med.  Wochenschr.,  1904, 
p.  ()32; — Zur  I'V.igc  der  Rontgciitherai)ie  des  Karzinoms.  Arch.  f.  klin.  Chir.,  Bd.  74, 
1901,  |>.   100. — I'riersen  and  Exnir.     Ueber  Ilefepilze  und  Geschwiilstbildung.     Beitr. 


GENERAL   DISCUSSION   OF   THE  TREATMENT   OF   TUxMORS       777 

z.  klin.  Chir.,  Bd.  2.5,  1899,  p.  7G8. — Rcpin.  La  toxitherapie  des  tumeurs  malignec. 
Revue  de  chir.,  1895,  vol.  15. — Itibbert.  Geschwiilstlehre.  Bonn,  1904; — Beitr.  z. 
Entstehung  d.  Geschwiilste.  Bonn,  1906. — Schmieden.  Erfolgreiche  experimentelle 
Verlagerung  von  Nebennierengewebe.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  70,  1904,  p.  453. 
— Virchow.  Die  krankhaften  Geschwiilste.  Berhn,  1863. — Vischer.  LTeber  Sarko- 
miibertragungsversuche.  Beitr.  z.  klin.  Chir.,  Bd.  42,  1904,  p.  617. — Wilms.  Im- 
plantation und  Wachstum  embryonaler  Gewebe.  Chir.  Kongr.-Verhandl.,  1904,  I, 
p.  287. — Wyss.  Zur  Entstehung  d.  Rontgenkarzinonies  der  Haut  u.  s.  w.  Beitr.  zur 
klin.  Chir.,  Bd.  49,  1906,  p.  185. — Ziegler.     Lehrbuch  der  allgenieinen  Pathologic.     Jena. 


50 


II.     DIFFERENT    VARIETIES    OF    TUMORS 

A.     CONNECTIVE-TISSUE   TUMORS 
CHAPTER   I 

PIBROMAS 

A  BENIGN  tnmor  composed  of  fibrous  tissue  is  called  a  fibroma.  Fi- 
bromas  occur  as  round  or  pedunculated  tumors  upon  the  skin  and 
mucous  membrane,  often  becoming  very  large.  They  may  be  congenital 
or  develo])  at  any  time  of  life. 

Mode  of  Growth. — They  grow  slowly  in  an  expansive  way,  and  there- 
fore belong  to  the  benign  tumors.  The  surrounding  tissues  are  dis- 
placed or  undergo  a  pressure  atrophy.  Pressure  atrophy  may  occur 
even  when  the  adjacent  structure  is  bone.  There  is  no  tendency  to 
recur  after  excision  except  in  that  variety  known  as  keloids. 

Histological  Characteristics.— A  fibroma  is  composed  of  cells,  con- 
nective-tissue fibrillar  and  blood  vessels.  The  first,  with  their  long, 
oval  nuclei  and  narrow  zone  of  cytoplasm,  resemble  the  cells  of  ordinary 
fibrous  tissue.  Cells  with  large  nuclei  and  rich  in  protoplasm  also  occur 
in  rapidly  growing  fibromas.  The  intercellular  substance  is  composed 
of  a  large  number  of  fibrilhw  Sometimes  these  fibrilla?  are  single,  at 
other  times  grouped  to  form  a  bundle  of  fibrilla?  which  are  closely  or 
loosely  arranged.  Fibromas  present  a  number  of  different  forms,  de- 
pending upon  llic  iiniiilx'i-  of  cells  and  tlic  grou])ing  of  the  fibrilUp. 

The  Hard  Fibroma,  or  Desmoid,  and  Soft  Fibroma. — The  hard  fibroma, 
or  desmoid,  white  and  shining  upon  section,  is  composed  of  thick,  coarse 
bnndh's  of  fibers  with  few  cells.  The  soft  fibroma  (fibroma  molluscum) 
is  grayish  white  upon  section,  and  is  composed  of  delicate  bundles  of 
fibrilla-  or  single  fibers,  between  which  are  tissue  fluids  containing 
lympliocytcs  and  leucocytes,  often  giving  to  the  tumor  an  cedematous 
appearance. 

Relation  to  Surrounding  Structures. — Fibromas  are  usually  intimately 

connected  with  the  surr-ounding  tissues,  but  in  spite  of  this  they  may 

easily  enucleate  in  many  cases.     If  the  tumor  develops  in  muscles  it 

will  contain  mus(;le  fibers.    NerA^e  fibers  and  glands  are  found  in  fibro- 

778 


FIBROMAS  779 

mas  developing  in  nerves  and  glandular  organs.  Bone  is  not  infre- 
quently found  in  periosteal  fibronias.  As  these  fibronias  develop  from 
the  fibrous  tissue  of  the  periosteum,  the  bone  which  they  contain  is  of 
periosteal  origin. 

i\Iany  fibronias  are  the  result  of  disturbances  of  development ;  for 
example,  the  congenital  tumors  of  the  skin  and  nerves  and  those  cover- 
ing an  encephalocele  or 
a  spina  bifida  occulta. 
In  many  forms  (keloid, 
elephantiasis  nervorum) 
there  is  a  distinct,  even 
hereditary,  predisposi- 
tion. Some  fibronias  de- 
velop from  inflammatory 
proliferations. 

It  is  not  possible  to 
make  a  sharp  distinction 
between  fibronias  and  the 
two  other  forms  of  tissue 
proliferation.  C Ji  ron  ic 
inflammatory  growtJis  of 
the  skin  and  subcuta- 
neous tissue   and   COngen-  Fig.  283.— Hard  J^ibroma  with  Few  Vessels. 

ital  hypertrophies  (par- 
tial giant  growth)  lead  to  the  formation  of  tumorlike,  elephantous 
masses.  If  these  are  sharply  circumscribed  and  distinguished  from  the 
surrounding  structures  by  a  more  independent  growth — for  example, 
if  they  contain  lobulated  or  pedunculated  parts — they  are  to  be  re- 
garded as  lobulated  elephantiasis  and  classified  with  fibronias.  It  is 
often  difficult  to  differentiate  between  a  fibroma  and  a  fibrosarcoma, 
which  may  develop  from  the  former.  If  the  tumor  is  rich  in  cells 
with  large,  oval  nuclei  undergoing  rapid  division  and  with  a  large 
amount  of  cytoplasm,  and  there  is  but  little  intercellular  substance,  the 
tumor  should  be  regarded  as  a  fibrosarcoma. 

The  vascularity  of  fibromas  varies  greatly.  If  the  blood  vessels, 
which  are  represented  by  spaces  of  different  size  lined  by  endothelium, 
are  present  in  large  numbers  (e.  g.,  in  many  nasal  and  pharyngeal 
polypi)  the  tumor  may  be  designated  as  a  fibroma  teleangiectaticum, 
or,  if  it  contains  large  sinuses,  as  a  fibroma  cavernosum.  The  fibroma 
lymphangiectaticum  is  provided  Avith  numerous  dilated  lymphatic 
vessels. 

Regressive  Changes. — A  number  of  regressive  changes  may  occur  in 
fibromas.     The  vessels  may  be  occluded  by  the  pressure  of  neighboring 


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780 


DIFFERENT   VARIETIES   OF   TUMORS 


structures  or  as  the  result  of  torsiou  of  the  pedicle,  and  the  tiunor  may 
then  undergo  necrosis.  As  the  result  of  liquefaction  of  the  intercellu- 
lar substance,  areas  containing  mucoid  tissue    {fihroma  myxomatodes) 

and  cavities  {fibroma  cysticum)  de- 
velop. 

Mixed    forms    of    these    tumors 

are  frequent,  fibrolipomas  occurrinji; 

in  the  subcutaneous   and  subserous 

tissues,  fibromyomas 

in  the  uterus. 

Fibromas  are  com- 
mon, occurring  upon 
different  parts  of  the 
body,  some  parts  be- 
ing more  frequently 
involved  than  others. 
Eight  varieties  may 
be  differentiated,  de- 
tf    i^lfc*  N.^rf'^L.  pending  upon   the  tissues  involved. 

>l    '  ^IpQMh^  I-  Fibromas   of  the   skin  appear 

ill  five  different  forms: 

(a)  The  soft  wart  (flesh  wart, 
verruca  carnea)  occurs  as  a  small, 
round,  usually  pigmented  formation 
with  a  broad  base  and  smooth  or 
wrinkled  surface.  It  is  either  con- 
genital or  develops  in  childhood  from 
small  congenital  pigmented  moles, 
and  may  become  transformed  into 
the  larger  lobulated  and  peduncu- 
lated soft  fibroma. 

They  develop  most  frequently, 
when  single,  upon  the  face  and  neck. 
If  associated  with  a  general  fibro- 
matosis of  the  nerves,  they  may  be 
disseminated  over  the  entire  surface 
of  the  body,  alternating  witli  numerous  flat,  wartlike  nam  and  larger 
Hi)roiiias. 

Accordiiin  j,,  Soldan,  liistolonically  they  are  soft  fibromas  rich  in 
cells,  iiiid  (l<'V('lu|)  j'roiii  the  coiiiiectivc-tissue  cells  of  the  cutaneous 
ni'i'vcs. 

Tlii'V  call  he  cjisily  dilTcrciil  intcd  from  oi'diiiary  warts,  which  are  so 
rn-fjiiriit  upon  llie  luiiids  of  children.     The  ordinary  warts  differ  from 


Fig.  284. — Fibromata  Mollusca  of  the 
Skin  and  Sarcoma  of  the  Left  Ax- 
illary Fossa. 


FIBROMAS 


781 


those  described  above:  (1)  In  that  they  are  transferable  to  diflferent 
parts  of  the  same  indivi(hial,  as  the  experiments  of  Jadassohn  and  Lanz 
have  shown;  (2)  they  are  the  result  of  the  hypertrophy  of  the  papillai 
and  the  skin  covering  them  and  depending  upon  the  condition  of  the 
latter;  their  surfaces  are  smooth,  rough,  or  fissured.  There  are  some 
other  forms  of  congenital  warts  or  papillomas  which  belong  to  the 
iibro-epithelial  tumors. 

(Z>)  The  multipje,  painless  tumors  of  the  skin,  which  are  some- 
times nodular,  sometimes  pedunculated,  are  designated  as  fihromata  mol- 
lusca.  They  vary  in  size,  and,  according  to  von  Recklinghausen,  develop 
from  the  cutaneous  nerves,  belonging  therefore  to  the  neurofibromas. 
Not  infrequently  they  contain  the  most  delicate  plexiform  neuromas 
{vide  p.  793). 


Fig.  285. — Lobtjlated  Ei.eph.\xtiasis  (Elephantiasis  Nervoiu-.m). 


(c)  Under  the  term  Johidaied  elephantiasis  are  grouped  a  number 
of  different  fibrous  growths  of  the  skin  which  resemble  each  other  in 
that  they   are   composed   of   long,   pendulous    growths,   folds,    flaps,    or 


782 


DIFFERENT    VARIETIES   OF   TUMORS 


masses.  Part  of  these  growths  belong  to  the  lymphangiomas  and  haem- 
angiomas  (elephantiasis  lymph-  and  ha?mangiectatica)  ;  part  are  soft 
fibromas  Avhich,  like  the  nodidar  soft  fibromas  of  the  skin,  develop  from 
the  connective  tissue  of  cutaneous  nerves,  but  they  also  contain  numerous 
lymphatic  and  blood  vessels   (von  Esmarch  and  Kulenkampff). 

The  nerve  form  of  elephantiasis  may  be  congenital  or  develop  in 
early  childhood  from  soft  fibromas.  The  tumors  occur  most  frequently 
upon  the  face  and  scalp,  upon  the  neck,  and  about  the  region  of  the 
shoulder.  They  are  covered  by  thin,  wrinkled  skin  which  is  often  pig- 
mented and  covered  with  hair. 

There  are  frequently  found  associated  with  the  fibrous  growths 
occurring  in  this  form  of  elephantiasis,  other  tumors  which  belong  to 
the  neurofibromas,  such  as  the  soft  wart,  fibromata  mollusca,  the  plexi- 
form  neuromas  in  the  base  of  the  lobulated  growths,  and  finally  fibromas 
of  the  larger  nerves ;  changes  which  von  Bruns  has  placed  in  one  group 
and  to  which  he  has  given  the  name  of  elephantiasis  nervorum.  Almost 
all  of  these  forms  are  associated  with  congenital  changes  in  the  skin, 
indicated  by  small  and  large,  usually  flat,  light-brown  pigmented  areas. 
Just  as  a  soft  wart  may  become  transformed  into  a  larger  fibroma  and 
these  into  lobulated  formations,  so,  according  to  Soldan,  each  pigmented 

mole  at  any  time 
may  become  trans- 
formed into  a  soft 
wart  or  into  multi- 
ple fibromas  of  the 
skin.  The  cell  col- 
unnis  of  these  pig- 
mented nrevi  with  al- 
veolar arrangement 
are,  according  to  the 
researches  of  this  in- 
vestigator, neither  of 
e{)itlielial  nor  of  en- 
dothelial origin,  but 
are  derived  from  the 
connective  tissues  of 
the  nerves  of  the 
cutis.  These  histo- 
logical findings  cor- 
respond perfectly  to  the  clinical  picture  as  the  flat,  more  rarely,  ver- 
rucous nievi,  soft  w.arts,  fibromas  of  the  skin,  and  deeper  nerves  are 
fre(piently  associated. 

Independent   growths   deve]()i)ing   fi-oni    inllai.n.iatory   hyperplasias, 


I'lu.  280. — Fibroma  Pendui 


FIBROMAS 


783 


which  are  secondary  to  repeated  attacks  of  erysipelas,  and  infections 
with  filaris  sanguinis  hominis,  do  not  belong  to  lobiilated  elephantiasis. 
(d)  The  hard  fibroma  of  the  skin  is  less  frequently  of  congenital 
origin  than  is  the  soft  fibroma.  It  appears  as  a  small,  hard  nodule  or 
as  a  slowly  growing  fungoid,  pendulous  tumor  with  a  long,  thin  pedicle. 


Fig.  287. — Fungiform,  H.'VRD  Fibroma  of  the  Skin  with  Section  of  the  S.\me. 


The  latter  form  may  develop  at  any  period  of  life.  It  occurs  most  fre- 
([uently  upon  the  back,  the  inner  side  of  the  arms  and  thighs.  There 
are  also  transitional  forms  to  the  soft  fibroma.  Upon  section  the  tumor 
is  sharply  defined  against  the  subcutaneous  fat,  and  its  surface  is  cov- 
ered by  a  thin  layer  of  subepithelial  connective  tissue. 

Diagnosis. — The  diagnosis  of  fibromas  of  the  skin  is  not  difficult, 
notwithstanding  the  great  number  of  different  forms  that  are  met  with. 
If  it  is  foimd  upon  section  or  microscopic  examination  that  the  epi- 


784  DIFFERENT   VARIETIES   OF  TUMORS 

theliiim  has  proliferated  to  form  part  of  the  tumor,  it  should  be  placed 
in  the  fibro-epithelial  group  (Ribbert).     Growths  occurring  in  this  form 

of  elephantiasis,  which 
become  smaller  under 
pressure,  are  either 
closely  related  to  or  be- 
long to  lymphangiomas 
and  hsemangiomas. 

Treatment.  —  These 
growths  should  be  ex- 
cised when  they  become 
so  large  or  are  so  situ- 
ated   that    they     cause 

Fig.  288. — Fibroma  of  the   Skin  with  Broad  Base  as  t n  .-,  .-, 

It  Appears  upon  Section.  trouble.      If  the  grOWths 

in  elephantiasis  are  ex- 
tensive, partial  excision  at  a  number  of  different  sittings  is  indicated. 
In  the  congenital  forms  the  proliferated  connective  tissues  and  the 
subcutaneous  nerves  must  be  carefully  removed  in  order  to  prevent 
recurrence.  The  defects  resulting  from  operations  upon  both  the  con- 
genital and  acquired  forms  of  elephantiasis  should  be  repaired  by  skin 
grafting  or  plastic  operations. 

(e)  Keloids  form  a  special  group  of  fibromas  of  the  skin.  They  are 
hard  tumors,  relatively  rich  in  cells,  and  are  composed  of  thick  bundles 
of  connective-tissue  fibrils  which  frequently  become  transformed  into 
homogeneous,  collagenic  trabecular.  Sometimes  they  occur  as  painless, 
red,  indurated  thickenings  of  the  skin,  sometimes  as  nodular  new  growths 
of  considerable  size,  and  sometimes  in  the  forms  of  tumors  sending  out- 
growths into  the  adjacent  healthy  tissues. 

The  growth  involves  only  the  reticular  layer  of  the  cutis.  It  never 
extends  to  the  deeper  structures  (Fig.  289).  A  keloid  is  therefore 
always  displaceable  with  the  skin,  and  may  be  raised  from  the  under- 
lying structures.  The  surface  of  a  keloid  is  red  and  shining  and  is 
covered  by  a  layer  of  epidermis  which  contains  no  papillae  and  is  not 
cornified,  and  by  a  thin  layer  of  vascular  connective  tissues.  The  tis- 
sue's composing  a  keloid  gradually  fuse  with  the  healthy  surrounding 
tissues,  and  the  boundaries  of  such  a  growth  are  therefore  never  sharp 
and  distinct.  The  neighboring  tissues  are  pushed  aside  and  separated 
by  the  expansive  growth  of  these  tumors.  Tliey  contain  neither  elastic 
fibci's,  hair,  nor  sebaceous  glands. 

(Ucalririal  and  Spontaneous  Keloids. — The  majority  of  keloids  de- 
velop within  a  cicati-ix.  They  inci-ease  gi-adually  in  size,  often  for  a 
number  of  nionllis,  and  tluMi  remain  stationary  or  in  rare  cases  disap- 
pear s|ii)nliineoiisly.      They   develop   most  commonly   in  scars   resulting 


FIBROMAS 


785 


from  burns  of  the  third  degree  and  from  cauterization,  but  also  in  sup- 
purating wounds  and  wounds  healing  by  primary  union,  from  chronic 
ulcers,  vaccination  scars,  and  from  contusions  of  the  skin.  Since  Ali- 
bert's  description  (1814)  the  keloids  following  wounds  have  been  spoken 


^^1^'- 


Fig.  2S9. — a,  Keloid  which  Dkvkloped  upon  the  Forearm  of  a  Child  Eiout  Years  of 
Age  after  a  Scald,     b,  Section  Through  the  Same. 


of  as  cicatricial  keloids  and  differentiated  from  spontaneous  keloids. 
Histologically  they  are  alike,  and  the  spontaneous  development  of  the 
latter  is  probably  only  apparent,  as  they  develop  after  some  insigniticant 
wound  or  injury  of  the  cutis  in  Avhich  there  has  been  no  separation  of 
the  epidermis. 

The  Hypertrophied  Scar  and  Differences  Between  It  and.  a  Keloid. 
— The  hypertrophied  scar,  which  appears  as  red,  frequently  very  pain- 
ful, hard,  flat,  or  irregular  tuitiorlike  growth  at  the  site  of  a  former 
injury,  is  not  to  be  regarded  as  a  keloid.  It  is  not  strictly  speaking  a 
new  growth,  but  is  the  result  of  excessive  scar  formation  in  the  most 


786 


DIFFERENT   VARIETIES  OF   TUMORS 


superficial  layers  of  the  cutis.  A  hypertrophiecl  scar  develops  most  fre- 
quently from  infected  wounds.  Wavy,  loose,  connective-tissue  bundles 
without  deposits  of  collagen  (Goldmann),  normal  connective-tissue 
cells,  frequently  also  cellular  infiltrations  and  isolated  hair  follicles  are 


Fig.  290. — Kkloid  Developing  in  a  Latarotomy  Wound 
(Young  Woman,  Twknty  Ykars  Old). 

Idiiiid  ill  a  hyperti'ophied  scar,  and  these  histological  findings  enable 
one  to  differentiate  between  such  a  scar  and  a  keloid. 

A  liypcrtr-ophied  scar  also  differs  from  a  keloid  in  that  the  scar 
tissue  slowly  undergoes  the  normal  changes  and  eventually  almost,  if 
not  (Mniiplctely,  disappears. 

J'()sili())is  in  which  Keloids  are  Most  Common. — The  position  of  the 
keloid  is  naturally  dc^termined  by  the  site  of  the  injury.  There  are, 
howevei-,  parts  of  the  body  in  wliicli  keloids  are  especially  prone  to 
devc^iop — for  example,  they  follow  more  fre(iuent!y  injuries  to  the  lobe 


FIBROMAS 


787 


of  the  ear,  breast,  face,  and  vaccination  scars  of  the  upper  arm,  tlian 
they  do  injuries  of  the  skin  of  the  palm  of  the  hand  and  the  sole  of 
the  foot.     Keloids  are  most  frequent  in  people  of  middle  age. 

Recurrence  after  Extirpation. — The  gxeat  tendency  to  recur  is  the 
most  important  characteristic  of  keloids.  Even  after  complete  extir- 
pation a  new  keloid  may  develop  within  some  weeks  within  the  resulting 
cicatrix.     It  makes  no  difference  whether  the  wound  has  been  sutured, 


Fig.  291. — A  Keloid  which  Di:vi;loped  in  a  Sutured  Wound  of  the  Arm  after  the 
Excision  of  a  Keloid  which  Developed  in  a  Vaccination  Scar. 


closed  by  a  plastic  operation,  covered  by  skin  grafts,  or  has  healed  by 
secondary  intention.  Small  nodules  will  even  develop  from  the  stitch 
holes  of  a  sutured  wound  (Figs.  290  and  291).     Only  in  rare  cases  is 


788 


DIFFERENT  VARIETIES  OF  TUMORS 


there  no  recurrence  after  extirpation.  Von  Bergmann  observed  a  case 
in  which  there  Avas  no  recurrence  after  seventeen  years.  In  spite  of  the 
fact  that  they  recur,  keloids  do  not  belong  to  the  malignant  tumors,  as 
they  do  not  form  m-etastases. 

Multiple  Keloids.— The  development  of  multiple  growths  is  another 
important  characteristic  of  keloids.  A  person  with  a  keloid  may  develop 
other  similar  growths  at  the  site  of  any  injury,   provided  the  injury 

has  involved  the  cutis 
(Lauenstein).  There  are 
cases,  however,  in  which 
extensive  injuries  and  op- 
eration-wounds of  parts 
of  the  body  some  dis- 
tance from  the  site  of 
a  keloid  heal  normally. 
The  different  results  fol- 
lowing wounds  indicate 
that  there  is  a  predispo- 
sition to  keloid  formation 
which  in  one  case  may 
be  general,  in  another 
case  local.  The  fact  that 
heredity  is  a  factor  in 
some  cases  also  speaks  for 
a  special  predisposition. 

Causes  of  Keloid  For- 
mation.— Negroes  are  pe- 
culiarly liable  to  develop 
keloids.  Nothing  is  known 
of  the  essential  cause  of 
]<rlni(l   j'onnation.     The  theory  advanced  by  Goldmann  that  absence  of 
the  connective-tissue  bundles  of  the  cutis,  resulting  from  injury,  is  the 
cause,  is  not  a  satisfactory  explanation. 

Didfjvosis. — The  diagnosis  of  keloids  is  not  difficult.  They  may  be 
confused  witli  large,  irregular,  hypertr()])liicd  scai's  (e.  g.,  after  burns 
and  cauterization). 

Treatment. — The  great  tendency  to  recur  must  always  be  consid- 
ered Ijcfore  treatment  is  instituted.  Excision  is  not  to  be  advised,  espe- 
cially if  recurrences  have  already  developed.  Goldmann  believes  that 
recurrence  may  be  prevented  if  the  wound  following  excision  of  a  keloid 
is  immediately  covered  by  large  epidermal  grafts.  According  to  the 
experience  of  the  author  proliferation  of  the  granulation  tissue  is  pre- 
vented Ijy  the  firmly  agglutinating  epithelium.     Recurrences  cannot  be 


1 1. 


I  i...i..\ci:;  Ai'  ii,ii  JC.vii.siox  oi-  A  Sponta- 
neous Keloid. 


FIBROMAS 


789 


prevented   with    certainty    either   by    this   procedure,    suturing    of   the 
wound,  or  by  plastic  operations. 

A  number  of  different  chemical  agents  have  been  used  in  the  treat- 
ment of  keloids.  Thiosinamin,  first  introduced  by  Ilebra  in  1892,  is 
the  best  agent.  It  is  frequently  used 
in  the  form  of  a  fifteen  per  cent  al- 
coholic solution  or  as  a  ten  per  cent 
aqueous  glycerin  solution,  as  recom- 
mended by  Duclaux.  The  solution 
should  be  injected  directly  into  the 
keloid.  After  a  number  of  injec- 
tions of  1  c.c.  the  keloid  becomes 
smaller.  If  the  keloids  or  hyper- 
trophied  scars  are  very  large  the  in-  ^^^^^ 

jections  must  be  continued  ^^^H.'  M^-^' 

for  a  number  of  months. 
The  injections  are  quite 
painful  to  a  number  of  pa- 
tients. This  method,  which 
at  least  causes  a  reduction 
in  the  size  of  the  keloid,  is 
to  be  preferred  to  excision. 
Fibrolysin  (Merck)  soluble 
in  water  is  a  double  salt 
of  thiosinamin  and  sodium 
salicylate.  [Hyde  aiid 
Ormsby  have  removed  a  number  of  keloids  with  the  X-ray.  This  should 
be  to-day  the  treatment  of  choice.] 

II.  Fibromas  of  the  subcutaneous  tissues  are  nnich  less  common  than 
those  of  the  skin.  They  may  occur  upon  almost  any  part  of  the  body 
at  any  period  of  life,  and  growing  slowly  may  attain  considerable  size. 
The  skin  covering  them  is  of  normal  appearance,  and  may  be  raised 
from  the  tumor.  These  tumors  are  encapsulated  and  may  be  displaced 
upon  the  underlying  fascia.  They  first  give  rise  to  symptoms  by  pres- 
sure upon  nerves. 

The  diagnosis  is  based  upon  the  slow  growth,  hard  consistency,  and 
encapsulation.     Extirpation  is  not  difficult. 

III.  Fibromas  of  the  mucous  membranes  occur  most  frequently  in 
the  nose.  They  are  usually  multiple.  The  pedunculated  or  lobulated 
nasal  polypi  are  composed  of  loose  or  fii-m  fibrous  tissue  which  contains 
large  vessels,  and  are  covered  by  a  stratified  epithelium  and  a  thin 
layer  of  subuuicous  tissue.  It  is  often  difficult  to  distinguish  between 
them  and  polypoid,  intiannnatory  growths  of  nnicous  membranes. 


Fig.  293. — Another  Recurrence  after  Four 
Years. 


790 


DIFFERENT    VARIETIES   OF   TUMORS 


Similar  but  smaller  multiple  tumors  are  found  in  the  larynx;  more 
rarely  in  the  gastro-intestinal  canal,  the  urethra,  and  bile  passages. 
Small,  circumscribed,  smooth  fibromas  may  also  be  found  in  the  mouth 
cavity  (on  the  tongue,  in  the  floor  of  the  mouth,  and  upon  the  gums). 

Laryngeal  and  nasal  polypi  should  be  grasped  with  special  forceps 
and  torn  away.  Sometimes  it  is  necessary  to  split  the  nose  or  larynx 
in  order  to  remove  these  tumors. 

IV.  Fibromas  of  the  fasciae  and  aponeuroses  are  hard,  nodular,  pain- 
less growths.  They  may  be  single  or  nniltiple.  These  tumors  develop 
most   frequently   in   the   abdominal   wall    (desmoid   of   the   abdominal 

wall),  taking  their  ori- 
gin most  often  from 
the  posterior  sheath  of 
the  rectus  muscle,  more 
rarely  from  the  ante- 
rior sheath,  from  the 
aponeuroses  of  the 
oblique  muscles,  from 
the  transversalis  fascia 
and  the  linea  alba. 
They  grow  slowly,  be- 
coming as  large  as  or 
larger  than  a  fist,  and 
separate  the  adjacent  muscles.  Their  growth  is  hastened  by  pregnancy. 
The  muscle  from  the  fascia  of  which  the  fibroma  develops  undergoes  in 
places  a  pressure  atrophy  as  the  tumor  extends  along  the  intramuscular 
connective-tissue  bundles  (Fig.  294). 

In  isolated  cases  a  number  of  these  tumors  have  been  found  in  the 
abdominal  wall,  one  developing  after  another.  Recurrence  may  occur 
after  excision,  but  it  is  rare  (vide  Pfeiffer). 

These  tumors,  as  a  rule,  develop  only  in  women  who  have  borne  chil- 
dren, and  it  is  probable  that  trauma  (slight  laceration  of  the  aponeu- 
rosis)  is  the  etiological  factor  in  their  development. 

The  diagnosis  is  based  upon  the  position  of  the  tumor  in  the  abdomi- 
nal wall,  its  hardness,  slow  growth,  and  round  form.  It  is  important 
to  determitie  the  relation  of  the  tumor  to  the  muscles  by  palpation  and 
by  rendei-ing  the  muscles  tense. 

After  removal  of  the  tumor,  the  defect  in  the  nuiscles  should  be 
sutured  in  order  to  prevent  a  hernia. 

Fihronids  of  the  neck  foi-m  aiiotlicr  cliiiicnl  group  of  tiunors  arising 
ri<tiii  fiisciii'  and  aponeuroses.  They  d(;v('l()|)  in  the  posterior  part  of 
till'  neck  iioiii  the  cervical  aponeurosis,  in  the  anterior  part  from  the 
sheath   of  llie  vessels,   ;it  tlic  sides  from  the  intermuscular  connective 


Fig.  294. — Fibroma  of  the  Internal  Oblique  Muscle  of 
THE  Abdomen  in  a  Female  Patient  Twenty  Years  of 
Age  (Natural  Size). 


FIBROMAS  791 

tissues.  They  may  take  their  origin  from  the  periosteum  of  the  ver- 
tebraB  and  from  the  dura  mater  of  the  cervical  part  of  the  spinal  cord 
(de  Quervain). 

V.  Fibromas  of  the  periosteum  are  most  common  upon  the  maxilla 
and  mandible  and  at  the  base  of  the  skull.  They  are  found  almost  always 
in  young  people  and  very  rarely  develop  on  other  bonas.  Thej^  belong 
to  the  hard  form  of  fibromas,  and  often  contain  many  large  vessels, 
frequently  cavernous  tissue.  Occasionally  they  contain  bone,  as  they  de- 
velop from  periosteum. 

Epulides. — Fibromas  of  the  jaw,  together  with  different  forms  of 
sarcomas,  form  part  of  the  clinical  group  of  tumors  known  as  epulides 
(epulis,  from  Ittl,  meaning  upon,  and  ovAts,  meaning  gum),  therefore 
those  tumors  which  are  situated  upon  the  gums.  Developing  from  the 
periosteum  of  the  alveolar  processes,  they  grow  between  the  teeth  as 
small  nodules  covered  with  mucous  membrane.  They  give  rise  to  symp- 
toms only  when  they  have  attained  considerable  size  or  ulcerate  and 


Fig.  295. — Fibrous  N.^sopharyngeal  Polyp  which  has  Invaded  the  Antrum  of 

HiGHMORE. 

bleed.  Lobulated  and  round  forms  of  periosteal  fibromas  occur  upon 
other  parts  of  the  jaw,  especially  upon  the  upper.  Central  fibroma.s 
are  most  common  in  the  jaw  bones,  developing  from  the  connective  tis- 
sue of  the  bone  marrow,  from  the  blood  vessels  or  nerves,  perhaps  also 
from  displaced  tooth-buds  (Blauel).     The  bone  gradually  undergoes  a 


792 


DIFFERENT   VARIETIES  OF  TUMORS 


pressure  atrophy  and  becomes  expanded  as  these  tumors  grow.  Finally 
they  may  rupture  through  the  thin  shell  of  bone  covering  them.  A 
tumor  of  the  upper  jaw  may  then  grow  into  the  antrum  of  Highmore. 
Fihromas  of  the  Vault  of  Pharynx. — The  hard  fibromas  Avhich  are 
found  in  the  vault  of  the  pharynx  and  develop  from  the  periosteum 
of   the   basilar   part   of   the   occipital   and   adjacent   bones    are   known 

as  fibrous  nasopharyngeal  polypi. 
They  are  covered  by  the  epithelium 
of  the  epipharynx  and  grow  in 
the  directions  in  which  there  is  the 
least  resistance.  These  tumors  are 
most  common  in  the  male  sex  be- 
tween the  fifteenth  and  twenty -fifth 
years.  First  they  occlude  the  pos- 
terior nares.  After  they  have  filled 
the  nasopharyngeal  space,  they  ex- 
tend into  the  pterygopalatine  fossa. 
The  surrounding  bone  undergoes 
a  pressure  atrophy,  so  that  finally 
tumor  masses  invade  the  acces- 
sory sinuses  of  the  nose,  the  sphe- 
noidal sinus,  and  the  skull  cavity 
(Figs.  295  and  296).  If  the  tu- 
mor ulcerates,  severe  haemorrhages 
from  the  fairly  large  vessels  may 
occur. 
These  tumors  are  not  infrequently  mistaken  for  malignant  tumors 
which  develop  from  the  base  of  the  skull  or  upper  jaw  and  extend  in 
much  the  same  way. 

It  is  often  necessary  to  perform  a  preliminary  operation  (temporary 
resection  of  the  upper  jaw)  in  order  to  render  these  tumors  accessible, 
so  that  a  radical  removal  may  be  performed  and  recurrences  prevented. 
VI.  Of  the  glandular  organs,  the  breast  is  the  most  frequent  seat 
of  fibromas.  Fihromas  occurring  in  this  organ  frequently  ccmtain 
glandular  elements  {vide  Adenoma).  Part  of  the  fibromas,  fibroade- 
nomas, and  fibrolipomas  occurring  in  the  kidney  are  the  result  of  de- 
velopiiKmtal  distui'bances.  These  tumors  are  most  frequently  situated  in 
the  pyramids,  enclosing  renal  tubules,  at  the  hilus,  and  beneath  the 
capsule,  and  may  attain  consideral)le  size. 

VU.  Fibromas  of  the  nerves  (fibromata  nervorum),  or  less  correctly 
s[)eaking,  neurofibromas,  are  fairly  conniion  tumors.  They  develop  from 
the  connective  tissue,  the  ends  and  pei-ineurium-  of  nerves,  and  are 
traversed  by  nerve  fibers  which  have  been  separated  by  the  growths  but 


Fig.  296. — The  Same  Tumok  Showing  In- 
vasion OF  THE  Skull  Cavity. 


FIBROMAS 


793 


have  not  proliferated.     Usually  these  tumors  are  multiple,  often  being 
present  in  large  numbers. 

Thej^  develop  most  frequently  upon  the  delicate  cutaneous  nerves. 
Their  relation  to  soft  fibromas  of  the  skin  and  elephantiasis  nervorum 
has  already  been  discussed  {vide  Fibromas  of  the  Skin,  p.  781). 

Fibromas  developing  upcni  the  larger  nerves  and  nerve  trunks,  in- 
cluding the  sympathetic  nerves  and  the  roots  of  cranial  and  spinal 
nerves,  lead  to  the  formation  of  flasklike  or  spindle-shaped  swellings; 
sometimes  to  the  formation  of  large  tumors  or  nodular  thickenings  which 
may  be  distributed  over  a  considerable  extent  of  the  nerves  involved. 

The  plexiform  neuroma  is  a  nodular,  fibrous  degeneration  of  a  par- 
ticular nerve,  usually  of  one  of  the  subcutaneous  nerves.  As  it  develops, 
the  nerve  involved  becomes  transformed  into  a  thickened,  nodular, 
wreathlike,  twisted,  tortuous,  circumscribed  mass.  Plexiform  neuromas 
may  also  develop  in  the  terminal  filaments  of  cutaneous  nerves,  and 
often  lie  concealed  beneath  soft  fibromas  of  the  skin  and  lobulated 
growths  occurring  in  elephantiasis. 

The  plexiform  neuroma,  if  not  present  at  birth,  begins  to  develop 
in  early  childhood.  Tumors  of  the  larger  nerves  grow  slowly  and  ap- 
pear in  middle  age. 
Even  these  larger  tu- 
mors have  some  rela- 
tion to  congenital 
changes  in  the  nerves, 
for  they  are  often  ap- 
parently merely  a  late 
manifestation  of  those 
changes  which  are 
comprised  under  the 
term  elephantiasis 
nervorum. 

The  cause  of  the 
formation  of  fibromas 
of  the  nerves,  likewise 
of  all  the  forms  of  ele- 
phantiasis of  nerves, 
must  be  sought  in 
some  disturbance  of 
normal  development  as  a  result  of  which,  perhaps,  there  is  an  irregu- 
lar distribution  and  arrangement  of  the  connective-tissue  elements  of  the 
nerves  permitting  of  independent  growth  (Ribbert). 

The  following  facts  may  be  cited  to  support  this  theory:  (1)   These 
tumors  develop  in  early  childhood;  (2)  they  are  multiple;  (3)  an  heredi- 
51 


™^ 


Fig.  297. — Nerves  Dissected  Free  from  a  Subcutaneous 
Plexiform  Neuroma  Removed  from  the  Occipital  Re- 
gion OF  A  Child  Four  Years  Old. 


794 


DIFFERENT   VARIETIES  OP  TUMORS 


taiy  history  may  be  elicited  or  a  congenital  predisposition  shown  as 
different  forms  of  elephantiasis  nervorum  (either  nenrofil)ronias,  soft 
fibromas  of  the  skin,  soft  warts  or  pigmented  nsevi)  may  be  demon- 
strated in  different  members  of  the  same  family. 

The  clinical  significance  of  fibromas  of  nerves  varies.  The  fibroma 
molluscum,  and  even  fibromas  of  larger  nerves,  may  give  rise  to  no 
symptoms.  The  most  freijuent  symptom  is  pain,  which  radiates  along  the 
nerve  from  the  tumor  toward  the  periphery.  It  is  increased  by  move- 
ments and  pressure.  However,  slight  functional  disturbances,  very 
rarely  sensory  and  motor  paralyses,  may  develop.  Frequently  these 
tumors  compress  adjacent  nerves  or  parts  of  the  brain  and  spinal  cord 
(fibromas  at  the  point  of  origin  of  cranial  and  spinal  nerves). 

Isolated  fibromas  of  nerves  do  not  recur  after  extirpation.  Some- 
times there  is  a  tendency  to  progressive  development  of  tumors  upon 
all  the  nerves  of  the  body  (von  Biingner).  In  twelve  per  cent  of  the 
cases    of   general   fibromastosis   of   the   nerves,   sarcomas    (fibrosarcoma 

and  myxosarcoma)  develop 
from  one  of  the  nodules, 
which,  according  to  Garre, 
should  be  called  secondary 
malignant  neuromas  to  dis- 
tinguish them  from  the  pri- 
mary sarcomas  developing 
in  nerves. 

The  diagnosis  of  fibro- 
mas of  nerve  is  not  diffi- 
cult when  they  are  multiple 
and  the  larger  nerves  are 
involved.  Where  there  are 
isolated  nodules  situated 
upon  deep  nerves,  one  is 
often  in  doubt  whether  the 
enlargement  is  a  lipoma,  a 
lymph  gland,  etc.,  which  is 
pressing  upon  an  adjacent 
nerve  and  giving  rise  to 
a  radiating  pain.  Other 
changes,  such  as  light- 
brown,  flat,  pigmented 
areas,  which  may  be  local- 
ized or  distributed  over  the  entire  surface  of  the  body,  are  frequelitly 
associated  with  these  fibromas  and  are  of  considerable  importance  as  a 
diagnostic  Hid. 


Fig.  298. — Pi.kxikohm  Neuroma  of  the  Subcutane- 
ous Nerves  of  the  Thorax  in  a  Boy  Eight  Years 
OF  Age.  (The  tumor,  about  as  largo  as  a  small  plato, 
was  flat  and  covered  by  normal  skin,  which,  however, 
was  somewhat  adherent  to  it.  .Surface  of  tumor 
somewhat  nodular.  Pain  upon  pre.ssure.  Tumor 
well  encapsulated  and  not  attached  to  underlying 
structures.  Many  flat,  pigmented  moles  in  the  skin 
adjacent  to  the  tumor.) 


FIBROMAS 


795 


Treatment. — The  treatment  consists  of  resection  of  the  part  of  the 
nerve  involved,  when  the  growth  is  limited  enough  to  render  this  possible. 

In  plexiform  neuromas 
the  skin  covering  them, 
which  has  undergone  an 
elcphantiasislike  hyper- 
plasia, should  also  be  re- 
moved. Recurrences  de- 
velop from  thickened 
nerves  which  are  left  be- 
hind. 

VIII.  Fibromas  of  the 
peritoneum  develop  from 
the  subserous  tissue  of  the 
mesentery,  mesocolon,  and 
omentum,  and  from  the 
retroperitoneal  tissues. 
They  grow  slowly,  form- 
ing hard,  somewhat  nod- 
ular tumors,  and  produce 
different  symptoms  de- 
pending upon  their  rela- 
tion to  the  viscera. 

These  tumors  often  con- 
tract firm  adhesions  with 

the  intestines  or  become  so  closely  related  to  the  blood  vessels  of  the 
intestines  that  it  is  often  necessary  to  resect  some  length  of  the  intes- 
tinal loops  in  removing  them. 

Literature. — Adrain.  Ueber  Neurofibroniatose  uinl  ihre  Koini)likation.  Beitr. 
z.  klin.  Chir.,  Bd.  31,  1901,  p.  1. — v.  Bergmann.  Demonstration  cines  vor  17  Jahren 
wegen  eines  grossen  Keloides  operierten  Patienten.  Verhandl.  d.  Bed.  med.  Gesellsch., 
1903,  I,  p.  206.— P.  Brutis.  Das  Rankenneurom.  Beitr.  z.  klin.  Chir.,  Bd.  8,  1892, 
p.  1. — V.  Biingner.  Ueber  allgem.  mult.  Neurofibrome  des  periph.  Nervensystems 
und  Sympathikiis.  Chir.  Kongr.-Verhandl.,  1897,  II,  p.  298. — Courvoisier.  Die 
Neurome.  Eine  klin.  Monographie.  Basel,  1886. — v.  Esmarch  and  Kulenkampff.  Die 
elephantiastischen  Formen.  Hamburg,  1885. — Garrb.  Ueber  sek.  malign.  Neurome. 
Beitr.  z.  klin.  Chir.,  Bd.  9,  1892,  p.  465. — Kiimmel.  Nasenrachenfibrome.  Im  Handb. 
d.  prakt.  Chir.,  Bd.  1,  2.  Aufl. — Lanz.  Leontiasis  mit  generalisiertem  Fibr.  moll. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  58,  1901,  p.  580;— Experim.  Beitriige  zur  Geschwulst- 
lehre.  Deutsche  med.  Wochenschr.,  1899,  p.  313.- — Leddcrhose.  Die  chir.  Erkrank- 
imgen  der  Bauchdecken.  Deutsche  Chir.,  1890. ^Lewaudowski.  Ueber  Thiosinamin 
und  seine  Anwendung.  Therap.  d.  Gogenwart,  1903. — Lexer.  Operation  eines  Mesen- 
terialfibromes  mit  ausgedehnter  Resektion  iles  Diinndarmes.  Berlin  klin.  Wochenschr., 
1900,  No.  1. — Olshausen.  Ueber  Bauchwandtumeren,  spez.  lib.  Desmoide.  Zeitschr. 
f.  Geburtsh.  u.  Gynak.,  Bd.  41,  1899,  p.  271. — Pjeiffer      Die  Desmoide  der  Bauchdecken 


Fig.  299. — Large  Fibkoma  (25  cm.  in  Diameter) 
Removed  from  the  Mesentery  of  a  Male  Pa- 
tient Forty-one  Years  of  Age.  During  the  op- 
eration it  was  necessary  to  resect  about  two  feet  of 
the  small  intestine  which  were  adherent  to  the  tumor. 
(Lexer.) 


796  DIFFERENT   VARIETIES  OF  TUMORS 

u.  ihre  Prognose.  Beitr.  z.  klin.  Chir.,  Bd.  44,  1904,  p.  334.— de  Quervain.  Ueber  die 
Fibrome  des  Halses.  Arch.  f.  klin.  Chir.,  Bd.  58.  1899,  p.  l.—v.  Recklinghausen.  Ueber 
die  multiplen  Fibrome  der  Haut  und  ihre  Beziehung  zu  der  mult.  Neuromen.  Berlin, 
1832. — Soldan.  Ueber  die  Beziehungen  der  Pigmentmaler  zur  Neurofibromatose. 
Arch.  f.  klin.  Chir.,  Bd.  59,  p.  261,  1899. — Wilms.  Zur  Pathogenese  des  Keloid.  Beitr. 
z.  klin.  Chir.,  Bd.  23,  1899,  p.  149. 


CHAPTER   II 

LIPOMAS 

Lipomas  are  tumors  in  which  is  reproduced  the  structure  of  normal 
fatty  tissue,  and  they  are  therefore  composed  of  more  or  less  lobulated, 
yellowish  masses.  They  may  be  single  or  multiple,  and  in  the  latter 
case  they  are  often  symmetrically  placed.  Lipomas  are  decidedly 
benign  and  do  not  recur  after  complete  extirpation.  They  are  rarely 
congenital,  developing  most  frequently  in  individuals  from  thirty  to 
fifty  yeai's  of  age  and  in  the  female  sex. 

Macroscopic  and  Microscopic  Appearance. — Lipomas,  excepting  the 
small,  multiple,  symmetrical  forms  which  sometimes  develop  within  a 
few  months,  grow  very  slowly.  They  develop  from  large  cells  which  in 
earlier  life  are  fat  free,  and  become  transformed  into  fat  cells  by  the 
deposition  and  coalescence  of  fat  droplets  within  their  cytoplasm.  Usu- 
ally the  cells  found  in  a  lipoma  are  larger  than  those  occurring  in 
normal  fatty  tissue.  Groups  of  these  fat  cells,  held  together  by  a  capil- 
lary network,  form  a  small  fat  lobule  which,  using  a  favorite  compari- 
son, bears  the  same  relation  to  its  nutrient  artery  that  grapes  do  to  the 
lateral  branches  of  the  stem.  The  lobules,  however,  are  not  separate  and 
distinct  as  in  normal  fatty  tissue,  but  are  united  by  connective-tissue 
trabecular  into  lai-ge  lobes  and  fingerlike  processes.  The  surface  of  the 
tumor  is  always  provided  with  a  thin  connective-tissue  capsule,  sending 
trabeduhe  into  deep  furrows  between  the  different  lobes,  which  are 
often  the  size  of  a  hen's  egg.  Even  when  non-lobulated  lipomas,  which 
are  rare,  are  cross-secticmed,  thin  connective-tissue  trabecule  may  be 
seen  passing  fi-om  the  capsule  into  tlic  dc])ths  of  the  tumor. 

The  capsule  of  a  lipoma  is  usunlly  but  loosely  attached  to  the  sur- 
rounding tissue.  If,  however,  the  tumor  is  exposed  to  irritation  (rub- 
bing of  the  clothing,  pressure  during  woi-k,  etc.),  the  capsule  becomes 
thickened  and  contracts  adhesions  Avith  the  skin  and  underlying  tissues. 
The  e;ipsul(!  then  becomes  fused  with  the  subcutaneous  fat  and  extir- 
|);i1ii>ii   is  rendered  diffieult. 

Independent  of  General  Nutrition. — A  lipoma  does  not  decrease  in 
size  wlien  ;i  p;ilii'iil  eiii;iei;ites  (Virchow).  The  complete  independence 
of  the  growth  is  best  shown  by  this  fact. 


LIPOMAS 


797 


Blood  Supply. — The  few  and  relatively  small  vesseLs  supplying  a 
lipoma  develop  from  the  subjacent  tissues  and  pass  into  the  tumor 
with  the  interlobular 
connective  tissue.  Fre- 
quently but  two  or  three 
arteries  are  fo\uid  even 
in  the  large  lipomas. 

Method  of  Growth. — 
The  surrounding  tis- 
sues are  displaced  by 
the  tumor  as  it  grows, 
and  large  proce.sses  are 
sent  out  into  the  loose, 
yielding  interspaces  of 
the  surrounding  struc- 
tures. In  this  way  a 
lipoma  grows  between 
muscles  and  tendons  or 
along  large  blood  ves- 
sels, extends  from  the  palm  to  the  dorsum  of  the  hand  between  the 
metacarpal  bone,  or,  developing  from  the  subserous  fat,  forces  its  way 


Fig.  300. — Extirpated  Subcutaneous  and  Intermuscu- 
lar Lipoma. 


>^ 


Fig.  301. —  Section  of  a  Subcutaneous  Fibrolipoma  of  the  Gluteal  Region.  The 
skin  and  a  thin  layer  of  subcutaneous  fat  pass  over  the  surface  of  the  encapsulated 
tumor. 


through  the  femoral  and  inguinal  canals  or  the  linea  alba  and  prepares 
the  way  for  hernia. 


798 


DIFFERENT  VARIETIES  OF  TUMORS 


A  lipoma,  which  is  nsuallj^  soft,  may  become  hard  if  the  fibrous 
tissue  is  increased  in  amount  (soft  and  hard  lipomas).  Depending  upon 
whether  the  fatty  or  fibrous  tissue  predominates,  one  speaks  of  a  lipo- 
fibroma  or  a  fibrolipoma.  If  there  is  a  marked  development  of  blood 
vessels  (proliferation  and  dilatation),  the  tumor  is  spoken  of  as  an 
angiolipoma.  If  the  fibrous  tissue  has  become  transformed  into  mucoid 
tissue,  or  if  there  are  smooth  muscle  fibers  in  the  tumor,  it  is  described 
as  a  myxolipoma  or  myolipoma. 

Regressive  Changes. — Calcification,  oecasionall.y  ossification  of  the 
septa,  (Edematous  changes  and  liquefaction  resulting  in  the  formation 

of  oillike  masses  (oil 
cysts)  occur,  especially 
in  the  larger  tumors. 
Nutritional  disturb- 
ances resulting  in  ne- 
crosis of  part  of  the 
tumor  and  the  skin 
covering  it,  with  sub- 
sequent erosion  of  ves- 
sels and  putrefactive 
changes  may  also  de- 
velop in  the  larger 
growths. 

Origin  and  Causes 
of  Lipoma. — Many  li- 
pomas, especially  those 
occurring  as  hetero- 
plastic tumors  in  vis- 
cera and  tissue  nor- 
mally containing  no 
fat,  and  as  congenital 
tumors  situated  over 
defects  in  the  skull 
and  vertebra?  (enceph- 
alocele,  spina  bifida 
occulta),  develop  from 
displaced  germinal  tis- 
sues. A  hereditary  influence  has  been  observed  in  rare  cases  only 
CHlaschko).  (irosch,  Kiittnitz,  Payr,  and  others  have  suggested  that 
Ihi-  imilliple,  syiiiiiietrieal  lipomas  are  of  li-ophoneurotic  origin,  and  the 
first  has  jittenipled  to  show  that  certain  tumors  are  prone  to  develop 
n|)on  cert  Mill  p;irt,s  of  the  body  because  of  anatomical  conditions  and 
slnicluijil  |.e(Mili;iiiti,.s.     After  an  exhaustive  study  concerning  the  dis- 


:{"2. — Subcutaneous  Lipoma  of  thk  Arm. 


LIPOMAS 


799 


tribution  of  lipomas  upon  the  suri'aee  of  the  body,  Grosch  came  to  the 
conclusion  that  lipomas  are  most  common  in  those  areas  where  there 
are  the  fewest  glands,  and  least  common  where  the  glands  are  most  nu- 
merous, .  that  therefore  lipomas 
are  most  common  in  those  areas 
where  the  least  fat  is  secreted. 
It    has    been    frequently    sug- 
gested that  there  is  a  causal  re- 
lationship   between 
a  single  trauma  and 
the  development  of 
lipomas.      This    re- 
lationship   has    not 
been   demonstrated. 
It    cannot    be    de- 
nied, however,  that 
long-continued  irri- 
tation, as,  for  exam- 
ple, when  the  part  of  the  body 
is  exposed  to  frequent  pressure, 
may  be  an  etiological  factor. 

Most  Common  Sites  for  the 
Development  of  Lipomas. — 
According  to  the  statistics  of 
Grosch  and  Stoll,  lipomas  de- 
velop most  frequently  in  the 
subcutaneous  connective  tissues 
of  the  shoulder  and  back.  They 
are  less  common  upon  the  front 

and  back  of  the  neck,  in  the  breast,  and  in  the  gluteal  region,  and  are 
but  rarely  encountered  upon  the  face,  scalp,  scrotum,  and  labia. 

Suhcutaneoiis  Lipoma. — Subcutaneous  lipomas  sometimes  appear  as 
small,  fiat,  at  other  times  as  nodular,  lobulated  growths,  the  si/e  of  a  fist 
or  a  man's  head.  Sometimes  a  lipoma  becomes  so  heavy  during  its  later 
growth  that  its  broad  base  is  drawn  out,  forming  a  relatively  narrow 
pedicle  (lipoma  pendulum).  An  ffdema  then  often  develops  as  the 
result  of  stasis,  and  when  the  tumor  is  incised  fluid  may  be  pressed  out 
as  from  a  wet  sponge. 

The  skin  covering  a  lii)oma  is  of  normal  appearance,  movable,  and 
may  be  raised  in  folds.  It  may  feel  thick  or  thin,  depending  upon  the 
amount  of  subcutaneous  fat.  If  the  skin  is  made  tense,  the  shallow 
depressions  between  the  different  lobules  of  the  tumor  may  be  distinctly 
seen,  especially  if  the  tumor  is  immediately  adjacent  to  the  skin, 


Fig.  303.^Stjbcutaneous  Lipoma  in  the  Re- 
gion OF  THE  Hip. 


800 


DIFFERENT   VARIETIES  OF   TUMORS 


A  lipoma  may  caiise  paiu  by  pressure  iTpon  nerves.  Multiple,  symmet- 
rical lipomas  are  frequently  painful  because  of  their  relation  to  the  con- 
nective tissues  of  the  cutaneous  nerves. 
Lipomas  may  be  so  situated  or  become 
so  large  that  they  cause  considerable 
discomfort.  Usually,  however,  they 
give  rise  to  but  few  symptoms,  and  it 
is  not  at  all  uncommon  to  see  a  patient 
who  has  carried  an  enormous  lipoma 
about  for  a  number  of  years. 


Fig.  .305.- SuncuTANEOus  Lii>oma  which  has 
DKKN  CJiiowiNn  Graduai^i^y  von  Fifteen 
YBAns.  The  skin  covering  the  tumor  is  very 
oedematons. 


Fig.  304. — Subcutaneous  and  Partlt; 
Intermuscular  Lipoma  of  the 
Back. 

Fascial  and  Aponeurotic 
Lipomas.  —  As  compared  with 
subcutaneous  lipomas,  those  de- 
veloping within  fascia?  and  apo- 
neuroses and  intermuscular  con- 
nective tissue  are  not  common. 
These  different  forms  are  prone 
to  develop  in  particular  regions 
of  the  body,  and  a  knowledge 
of  the  most  common  sites  aids 
considerably  in  making  a  diag- 
nosis. 

The  small,  round,  rarely  lob- 
ulated  lipomas  occurring  about 
the  head  are  most  common  in 


LIPOMAS 


801 


the  frontal  rej^ion,  and  are  often  referred  to  as  pericranial  lipomas. 
They  lie  beneath  the  aponeurosis  or  muscular  fibers  of  the  occipito- 
frontalis,  and  are  (juite  firmly  attached  to  the  latter.  They  may  pro- 
duce a  pressure  atrophy  of  the  periosteum  and  external  plate  of  the 
subjacent  bone.  In  this  way  a  depression  is  made  in  the  bone  in  which 
they  lie,  and  they  resemble  closely  in  some  cases  dermoid  cysts  (von 
Bergmann). 

Lipomas  in  the  palm  of  the  hand  develop  most  frequently  be- 
neath the  palmar  fascia.  They  then  extend  between  the  metacarpal 
bones  to  reach  the  dor- 
sal surface  of  the  hand 
( Steinheil ) ,  Occasion- 
ally  lipomas  develop 
upon  the  fingers,  espe- 
cially upon  the  palmar 
surface,  being  either 
subcutaneous  or  at- 
tached to  the  bone. 

Subfascial  lipomas 
also  occur  in  the  neck, 
back,  and  abdominal 
wall.  They  send  off 
large  processes  between 
the  muscles.  Intermus- 
cular lipomas  may  be 
encountered  in  the 
back,  beneath  the  pec- 
toralis  ma,ior,  upon  the 
extremities,  and  in  the 
abdominal  wall.  Some 
of  the  lipomas  of  the 

cheek,  developing  from  the  sucking  pad,  and  of  the  tongue  are  inter- 
muscular forms;  others  develop  from  the  submucosa. 

Lipomas  Developing  within  the  Ahclominal  Cavity. — The  abdominal 
cavity  is  another  but  not  frequent  site  for  the  development  of  lipomas. 
A  portion  of  omentum  which  has  been  retained  in  a  hernial  sac  for  a 
number  of  years  may  proliferate  to  form  a  lipomalike  mass  (omental 
lipoma).  The  appendices  epiploicfe  at  times  become  so  large  that  they 
resemble  a  tumor,  and  they  may  become  detached,  forming  free  bodies 
in  the  peritoneal  cavity.  Small  subnmcous  lipomas  occur  in  the  stom- 
ach. The  largest  fatty  tumors  develop  from  the  retroperitoneal  tissues 
from  w^hich  growths  weighing  from  twenty  to  fifty  pounds  have  been 
removed,   sometimes  successfully    (statistics   of   Heinricius).     Lipomas 


^ 


Fig.  30('>. — I.homa  oi    ihe  Forehead. 


802  DIFFERENT    VARIETIES   OF   TUMORS 

of  the  mesentery  are  situated  either  at  its  root  or  along  its  intestinal 
attachment.  Subserous  lipomas,  developinj,^  from  the  properitoneal  fat 
and  extending  into  the  femor<d  and  inguinal  canals  and  through  the 
foramina  in  the  linea  alba,  dilate  these  openings  and  draw  a  funnel- 
shaped  process  of  peritoneum  after  them.  [Rose  and  Linhart  have 
emphasized  the  relationship  between  hernia  and  subserous  lipomas.  Un- 
doubtedly they  are  an  etiological  factor  in  a  number  of  cases.  They 
dilate  the  canal  and  draw  the  peritoneum,  which  forms  the  sac  after 
them.  Often  in  operating  for  a  small  hernia  of  the  linea  alba  in  the 
early  stages  a  small  subserous  lipoma  will  be  found,  unassociatcd  as  yet 
with  any  definite  sac] 

Lipomas  of  the  Different  Viscera. — Lipomas  are  rare  in  the  different 
viscera,  being  most  common  in  the  kidney.  The  small  tumors  which 
develop  in  the  latter  never  become  larger  than  a  walnut,  and  are  usu- 
ally situated  in  the  cortex.  They  often  contain  smooth  muscle  fibers. 
These  tumors  are  very  rare  in  other  organs,  such  as  the  lungs,  liver, 
heart,  uterus,  and  breast.  Small  lipomas  developing  from  the  pia  mater 
are  occasionally  found  at  the  base  of  the  brain. 

Lipoma  Arhorescens. — Lipoma  arborescens  is  a  particular  form  re- 
sulting from  the  proliferation  of  synovial  villi  and  associated  with  the 
formation  of  clublike  processes.  This  form  of  lipoma  is  associated  with 
different  chronic  inflammatory  processes  in  the  joints,  especially  of  the 
knee  joint,  where  it  was  first  observed  by  Joh.  Miiller.  It  is  occasionally 
found  ill  clironically  inflamed  tendon  sheaths,  especially  in  those  of  the 
hand  (Stieda,  Schmolk,  Ilaeckel). 

It  should  be  mentioned  that  lipomas  occasionally  develop  in  the  orbit, 
spermatic  cord,  tongue,  and  retromammary  tissues. 

Diagnosis. — The  diagnosis  of  superficial  lipomas  is  rarely  difficult. 
It  is  based  upon  the  position  of  the  tumor,  its  slow  growth  and  well- 
defined  boundaries,  mobility,  lobulated  structure,  pseudo-fluctuation 
and  consistency,  which  is  sometimes  soft,  sometimes  hard.  Usually  the 
painful  lipomas  are  symmetrical,  flat,  and  somewhat  nodular,  and  may 
be  easily  differentiated  from  the  round,  spindle-shaped  fibromas  devel- 
oi)iiig  upcm  the  nerves.  If  the  surface  of  the  tumor  cannot  be  pal- 
l)aled  and  its  boundaries  cannot  be  definitely  defined,  the  diagnosis  of 
a  benign  tumor  may  be  made,  but  frequently  nothing  definite  can  be 
sfiid  concerning  the  variety.  In  doubtful  cases,  cystic  formations  (der- 
moids, echinocoecus  cysts,  hygromas)  and  tuberculous  abscesses  may  be 
excluded  by  aspiration.  A  lipoma  of  the  forehead  differs  from  a  peri- 
oslcnl  gimiiiiji  by  being  more  mobile.  Large  lipomas  of  the  peritcmeal 
cavity  may  be  regarded,  because  of  their  hardness,  as  fibromas  or  fibro- 
sarcomas, the  soft  form  as  an  ascites  or  an  encapsulated  tuberculous 
a])scoss.     It  is  often  difficult  to  differentiate  between  a  retromammary 


LIPOMAS 


803 


lipoma  and  a  lipoma  witliiii  the  breast  i)rop(.r,  between  a  lij)nma  be- 
neMth  tlie  paj'otid  <>];ind  and  one  within  it. 

Technic  of  Removal.— Usually  the  removal  of  a  falbj  tumor  is  not 
difficult.      I  The  tumor  .should  be  seized  between  the  thumb  and  index 


Fig.  307. — Diffu.se  Svmmktkual  Lipc 


finger  of  the  left  hand  and  the  sldn  made  tense.  An  incision  is  then 
made  down  to  the  capsule  and  often  the  tumor  fairly  pops  out  If  any 
difficulty  is  encountered  the  tumor  may  be  seized  with  sharp  hookJ  o'r 
retractors  and  pulled  from  its  bed,  the  dissection  being  completed  with 


804  DIFFERENT  VARIETIES  OP  TUMORS 

the  fingers,  thick  septa  being  divided  with  scissors.]  In  the  excision  of 
large  tumors  a  sufficient  portion  of  tlie  thinned  or  (i-dematous  skin 
covering  the  tumor  should  also  be  removed. 

Diffuse  Lipomas. — Clinically,  a  diffuse  lipoma  is  differentiated  from 
the  circumscribed,  encapsulated  form.  These  diffuse  lipomas  may  be 
congenital,  being  associated  with  partial  giant  growths  of  the  extremi- 
ties, or  may  occur  as  nuiltiple,  symmetrical  growths  in  middle-aged 
people.  They  surround  the  neck  as  broad  nodular  growths  (the  so- 
called  fatty  neck  of  IMadelung)  and  occur  upon  the  trunk  and  extremi- 
ties as  transverse  and  oblique  masses  (Fig.  307). 

These  diffuse  lipomas,  described  by  Billroth  as  lipomatosis  rcgionaria, 
are  not  tumors  strictly  speaking,  but  are  merely  localized  accumulations 
of  fat,  secondary  to  an  excessive  development  of  fat  in  the  individual. 
-[They  usually  develop  in  people  who  drink  large  quantities  of  beer 
and  eat  to  excess,  and  dift'er  from  true  lipomas  in  that  they  decrease  in 
size  when  beer  is  withdrawn  and  the  patient  is  compelled  to  take  exer- 
cise.] They  bear  the  same  relation  to  polysarcia  and  obesity  that  lobu- 
lated  fibroma  formation  does  to  elephantiasis  (Virchow). 

The  subcutaneous  fat  is  chiefly  involved  by  these  growths,  but  they 
may  extend  deeper,  passing  in  between  the  muscles.  Sometimes  it  is 
necessary  to  remove  these  growths,  especially  when  they  occur  in  the 
neck,  as  they  may  press  upon  the  trachea  and  interfere  with  breathing. 
A  complete  operation  can  never  be  performed,  however,  as  the  growths 
are  not  encapsulated.  The  tumors  do  not  recur  even  after  incomplete 
removal. 

Repair  of  the  sutured  wound  is  often  delayed  by  the  discharge  of  a 
serous  fluid,  containing  fat,  which  continues  for  some  time.  This  fluid 
may  even  seep  out  through  the  stitchholes. 

Literature. — Blaschko.  Erbliche  Lipombildung.  Virchows  Arch.,  Bd.  124,  1891, 
p.  175. — Ehrmann.  TJeber  multiple  symmetrische  Xanthelasmen  und  Lipome.  Beitr. 
z.  klin.  Chir.,  Bd.  4, 1889,  p.  341 . — Grosch.  Studien  iiber  das  Lipom.  Deutsche  Zeitschr. 
f.  Chir.,  Bd.  26,  1887,  p.  397. — Haeckel.  Lipoma  arborescens  der  Sehnenscheiilen. 
Zoiitralbl.  f.  Chir.,  1888,  p.  297. — Heinricius.  Ueber  retroperitoneale  Lipome.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  56,  1900,  p.  579  and  Arch  f.  klin.  Chir.,  Bd.  72,  1904,  p.  172.— 
Kottnltz.  Ueber  symmetrisches  Auftreten  von  Lipomen.  Deutsche  Zeitschr.  f.  Chir., 
Bd.  38,  1894,  p.  75. — Langer.  Zur  Kasuistik  der  multiplen  symmetrischen  Lijioine. 
Arch.  f.  klin.  Chir.,  Bd.  46,  1893,  p.  899.— Madelung.  Ueber  denn  Fetthals.  Arch,  f, 
klin.  Chir.,  Bd.  37,  1888,  p.  106; — Exstirpation  eines  vom  Mesenterium  ausgehenden 
Lipoma  oedematosum  myxomatodes  mit  partieller  Resektion  des  Dimndarmes.  Berl. 
klin.  Wochenschrift,  1881,  p.  75. — HcUmut  Mailer.  Ueber  die  Lipome  und  lipomatosen 
Mis(;hgosch\viilste  der  Niere.  Virchows  Arch.,  Bd.  145,  1896,  p.  339. — Payr.  Beitr. 
z.  L(!hre  von  den  multiplen  und  symmetrischen  Lipomen.  Wien.  klin.  Wochenschr., 
1895,  ]).  733. — Preyss.  Ueber  die  Operation  der  diffusen  Lipome  des  Halses.  Beitr. 
z.  klin.  Chir.,  Bd.  22,  1898,  p.  im.—Schmolk.  Zwei  Fiille  von  Lipoma  arborescens  genu. 
Deutsche  Zeitsclir.  f.  Chir.,  Bd.  23,  1886,  p.  273.—Steinheii.     Ueber  Lipome  der  Hand 


CHONDROMAS 


805 


und  Finger.  Beitr.  z.  klin.  Chir.,  Bd.  7,  1891,  p.  605. — Stieda.  Lipoma  arborescens. 
Beitr.  z.  klin.  Chir.,  Bd.  16,  1896,  p.  285. — Stoll.  Beitr.  z.  Kasuistik  der  Lipome.  Beitr. 
z.  klin.  Chir.,  Bd.  8,  1892,  p.  597. 


CHAPTER   III 


CHONDROMAS 


Tumors  which  are  composed  of  cartilage  are  called  chondromas. 
Those  chondromas  occurring  in  parts  which  normally  contain  no  carti- 
lage Avere  called  enchondromas  by  Virchow  to  differentiate  them  from 
ecehondromas,  which  develop  in  parts  normally  containing  cartilage. 
Enchondroma  i.s  therefore  synonymous  with  heterologous  chondroma. 
Hyperplastic  cartilaginous  growths  are  known  as  ecchondroses,  but  it  is 
often  impossible  to  make  a  sharp  distinction  between  tumorlike  and 
hyperplastic  growths  of  cartilage. 

Appearance  and  Histology. — Chondromas  are  nodular,  soft,  or  hard 
tumors  of  opalescent  appearance  resembling  normal  cartilage.  They 
are  often  multiple  and  may  appear  in  great  numbers.     Usually  they 


Fig.  308. — Multiple  Enchondkomas  of 
THE  Bones  of  the  Hand. 


Fig.  309. — Enchondroma  of  the  Thumb. 


develop  slowly,  but  sometimes  begin  to  grow  rapidly  and  become  quite 
large.     These  tumors  are  most  common  in  young  people. 

Histologically   they   differ  from   normal   cartilage,   as  the   cells   fre- 
quently do  not  possess  a  capsule,  are  less  regular  in  shape,  being  oval, 


806 


DIFFERENT   VARIETIES  OF  TUMORS 


round,  fusiform,  and  stellate,  and  are  not  arranged  according  to  any 
definite  plan.  The  ground  substance  consists  of  hyaline,  elastic,  or 
fibrous  cartilage.  The  different  nodules  composing  the  tumor  are  held 
together  by  vascular  connective  tissue,  which  may  even  penetrate  into 
the  cartilage.  Fibrous,  myxomatous,  osteal,  and  angiomatous  tissue  may 
develop  at  the  same  time  that 
the   cartilage   does,   and   mixed 


Fig.  310. — Roentgen-ray  Picture  of       Fig.  311. — Enchondroma  of  the  Second  Meta- 
A  Cortical  Enchondroma.  carpal  Bone  as  It  Appe.\rs  Externally  and 

UPON  Section. 


tumors,  such  as  fibroclK^idromas,  chondromyxomas,  and  osteochondromas 
are  formed.  As  a  result  of  the  excessive  proliferation  of  the  cartilage 
cells  the  tumor  may  become  transformed  into  a  sarcoma  (chondro-sar- 
coiiia.  or  if  bone  is  also  i)resent  into  an  osteochondro-sarcoma) . 

Method  of  Growth. — The  growth  of  chondromas  is  sometimes  expan- 
sive, sometimes  infiltrating.  Depending  upon  the  character  of  their 
growth,  these  tumors  are  sometimes  benign,  sometimes  malignant.  If 
the  tumor  is  surrounded  by  a  layer  of  tissue  resembling  perichondrium, 
it  merely  displaces  the  neighboring  structures  as  it  grows.  In  the  soft, 
cellular  forms  a  capsule  is  freciuently  wanting,  and  then  the  cartilage 
cells  grow  into  the  spaces  of  the  adjacent  tissues,  invade  the  veins  and 
lymphatic  vessels,  and  are  carried  to  the  lungs  and  lymphatic  nodes. 
A  (toiitinuous  growth  extending  from  a  chondroma  of  the  vertebra 
Ihrough  the  large  veins  to  the  heart  has  been  observed  (Ernst). 

Changes  Occurring  in  Chondromas. — Ossification  (ossifying  chon- 
droma; is  the  most  inipoi'tant  of  the  changes  which  a  chondroma  may 
undergo.     It  is  preceded  by  vascularization,  as  in  normal  bone  forma- 


CHONDROMAS 


807 


tion,  and  finally  the  eai'tilauiiious  tumor  is  ti-anst'oniicd  into  a  hony 
tumor,  the  only  indicatit)ii  ol'  its  cartilajiinoiis  ofit^in  hcin^-  a  tliiu  cover- 
ing of  cartilage. 

Fegressive  changes,  such  as  calcification,  my.\omatt)us  softening,  and 
cyst  formation,  are  common  in  chondromas.  They  are  usually  sec- 
ondary to  nutritional  changes  in  the  tumor  tissue.  If  myxomatous 
softening  occurs,  a  chondroma  myxomatodes  develops;  if  cyst  forma- 
tion a  chondroma  cijsticiim.  Occasionally  ulceration  of  the  skin,  the 
result  of  pressure,  is  ohserved.  Putrefaction  of  the  tumor  may  follow 
ulceration. 

Most  Common  Sites  of  Chondromas. — Chondromas  are  most  common  in 
the  bony  system.  Enchondromas  developing  in  bone  may  be  congenital; 
frequently  they  develop  during  the  first  two  decades  of  life.  They  occur 
most  frequently  upon  the  phalanges, 
metacarpal  and  metatarsal  bones  as 
single  or  multiple  tumors.  A  favorite 
locality  for  enchondromas  is  the  fin- 
gers, where  they  form  characteristic, 
shapeless,  nodular  masses.  These  tu- 
mors develop  more  frequently  from  the 
metaphysis  than  from  the  diaphysis 
(Nasse) ,  from  the  interior  than  from 
the  surface  of  bone.  The  bone  sur- 
rounding one  of  these  tumors  under- 
goes pressure  atrophy  and  a  cortical 
enchondroma  produces  deep  depres- 
sions in  the  surface  of  the  bone  in- 
volved, while  a  central  enchondroma 
gradually  destroys  the  bone  as  it  grows, 
so  that  finally  it  is  covered  only  by  a 
thin  shell  of  bone  or  periosteum.  In 
the  bone  which  is  not  destroyed  small 
islands  of  cartilage  may  be  found. 

In  the  long,  hollow  bones  th(>  metaphysis  is  the  favorite  site  iov  the  de- 
velopment of  cortical  and  intraosteal  chondromas.  The  phalanges  when 
involved  become  consideral)ly  enlarged.  These  tumors  may  interfere  with 
the  growth  of  long  bones,  and  when  involved  they  become  shortened  and 
'deformed,  changes  resembling  closely  those  associated  with  rickets.  In 
rare  cases  chondromas  develoj)  upon  one  side  of  the  body  only,  and 
then  the  growth  changes  are  unilateral  (Oilier,  A.  Wettek).  A  central 
-enchondroma  may  produce  such  an  osteoporosis  that  a  spontaneous 
fracture  occurs.  If  the  tumor  has  previously  given  rise  to  no  symp- 
toms and  caused  no  enlargement  of  bone,  it  is  often  difficult  to  deter- 


FiG.  312. — Cystic  Enchondroma  of  the 
Scapula  op  an  Adult. 


808 


DIFFERENT   VARIETIES  OF  TUMORS 


mine  wliether  the  fracture  was  secondary  to  the  tumor  or  whether  the 
tumor  developed  in  the  ealhis.  Cystic  softening  of  the  central  tumors, 
which  are  usually  fibrochondromas,  occasionally  follows  an  injury  and 
leads  to  the  formation  of  large  multilocular  or  coalescent  cysts,  the 
contents  of  which  consist  of  a  brownish  fluid  containing  disintegrated 

blood  and  cholesterin. 
'  Often  some  of  the  orig- 
inal tumor  tissue  is  found 
in  these  cysts,  and  the 
diagnosis  as  to  their  na- 
ture may  be  based  upon 
this  finding  (Virchow, 
Schlange,  Fritz  Konig, 
and  others).  If  no  tu- 
mor tissue  is  present, 
islands  of  hyaline  car- 
tilage at  some  distance 
from  the  epiphyseal  car- 
tilage, and  cartilaginous 
exostoses  in  the  walls  of 
the  cysts  indicate  their 
origin  and  enable  one  to 
distinguish  between  them 
and  the  cysts  (p.  749) 
occurring  in  osteitis  de- 
formans (Lexer). 

Of  the  bones  of  the 
trunk  those  of  the  pelvis 
and  the  scapula  are  most 
often  involved,  being  fre- 
(jucntly  tlie  site  for  the  development  of  very  large  tumors.  Chondromas 
develop  but  rarely  upon  the  ribs  and  skull  bones,  only  occasionally  upon 
the  vertebrae,  clavicle,  sternum,  and  hyoid  bone. 

In  many  eases  multiple  cartilaginous  exostoses  are  associated  with 
enchondromas  (Virchow,  von  Recklinghausen,  Nasse,  Lawen  (Figs.  310 
and  aifi). 

Kiiclioiidromas  are  the  result  of  some  interference  with  normal  bone 
formation,  consisting  either  of  a  defect  in  the  skeletal  anlage,  or  of 
pathological  changes  occurring  in  bone  during  intra-  or  extrauterine 
life.  The  cause  of  the  changes  in  normal  bone  formation  is  unknown. 
It  is  to  be  regarded  as  certain,  however,  that  chondromas  develop  froii^ 
gei-minal  cartilaginous  tissue  which  has  been  displaced  from  the  epiphys-* 
eal  zone  (Virchow)  into  tlie  bone  marrow  of  the  diaphysis.     It  is  prob- 


i:.  :;i:i.  ('i>iic  I;m  iium.hhm  \  <>>  ihk  Upper  Met- 
Ai'iivsis  OF  THE  Humerus  of  a  Child  Nine  Years  of 
Age,  Healed  by  Curetting  Out  the  Tumor  Tissue. 
Bony,  trabeculfE  are  still  present  between  the  nodules 
and  cysts  of  the  tumor. 


CHONDROMAS 


809 


able  that  a  number  of  these  tumors  originate  from  ishuids  of  cartilage 
wliich  have  been  displaeed  from  their  usual  position  during  an  attack 
of  rickets.  Von  liecklinghausen  believes  that  the  disturbance  in  bone 
formation  is  due  to  imperfect  development  of  the  blood  vessels.  The 
not  infrequent  association  of  multiple  ha^mangiomas  with  tumors  of 
this  character  lends  some  support  to  the  theory.  The  islands  of  cartilage 
cells  displaced  into  the  diaphysis  may  remain  dormant  or  give  rise  to 
tumor  formation  later.  If  the  tumor  develops  after  a  trauma,  the  lat- 
ter is  to  be  regarded  as  the  exciting  cause  which  stimulated  the  dormant 
island  of  cartilage  cells  to  growth. 

Chondromas  are  also  encountered  in  organs  and  tissues  which  nor- 
mally contain  no  cartilage,  developing  from   cartilaginous  rests  which 


Fig.  314. — Rone  Cysts  ix  thk  Humerus  of  a  Boy  Fouktken  Yeaks  ok  Age.  In  spite 
of  the  fact  that  there  was  no  tumor  tUsue,  a  diagnosis  of  a  previous  chondroma  could  be 
made  because  hyaline  cartilage  was  found  in  the  walls  of  the  cyst  and  some  medullary 
tissue  was  present.      (Lexer.)      Healing  followed  resection  and  transplantation  of  bone. 


have  been  displaced  during  development.     Cartilaginous  tumors  of  the 
diaphragm  develop  from  displaced  portions  of  the  skeletal  anlage,  of 
the  ovary  from  portions  of  the  primitive  vertebrae,  of  the  thyroid  and 
52 


810 


DIFFERENT   VARIETIES  OF  TUMORS 


salivary  glands  and  neck  from  portions  of  tlie  cartilages  of  the  brancli- 
ial  arches.  Tnniors  about  the  ear,  trachea,  and  bronchi  develop  from 
portions   of  the   aural   anlage,   from   tracheal   and  bronchial   cartilages 

respectively.    Pieces  of 

r^-s^- ":  ---^^u^mgg-        ■"  -   ...„.^.^-^<^      cartilage    which    have 

not  proliferated  are 
sometimes  found  in 
the  skin  of  the  cheek 
(auricular  appendages) 
being  derivatives  of  the 
aural  anlage.  Remains 
of  the  branchial  car- 
tilages are  also  found 
in  the  tonsils,  parotid 
glands,  and  the  lateral 
regions  of  the  neck. 
Reichel  observed  a 
chondroma  in  the  cap- 
sular ligament  of  the 
knee  joint  which  had 
developed  from  a  syn- 
ovial villus  containing 
cartilage.  Riedel  has 
encountered  chondro- 
mas in  the  wrist  joint, 
Langemak  in  tarsal 
joints,  Paulet  and  Hon- 
sell  in  different  mus- 
cles (masseter  and  del- 
toid) . 

Some  of  the  car- 
tilaginous growths  oc- 
curring in  the  salivary 
and  mammary  glands, 
ovary,  kidney,  and 
uterus   are   of   a   com- 


FlG.  31.">.        I.M   ll'i\]>K(iMAS    OF   THE    UpPER   MeTAPIIYSES    OF 

THE  Hones  oe  Both  Thu!us  Associated  with  Exosto- 
ses OF  the  Loweu  Ends  of  the  Bones  (Eleven-Yeak 
Oi,D  Hoy). 


plicated  structure  and 
are  not  to  be  classified  with  simple  chondromas.  The  rare,  multiple 
new  growths  occurring  as  small,  hard  nodules  upon  the  inner  side  of 
the  larynx  and  trachea;  as  larger  growths,  often  becoming  the  size  of 
an  a|)pl(^,  upon  the  costal  cartilages;  as  small  flat  projections  upon  the 
post(;rior  surface  of  the  symphysis  and  upon  tha  intervertebral  disks — 
are  known  as  cccJiondromas. 


CHONDROMAS 


811 


Diagnosis. — The  diagnosis  of  the  common  chondromas  is  not  dif- 
ficult. The  appearance  of  these  growths,  occurring  as  nodular  and 
usually  hard,  painless,  circumscribed  tumors  firmly  attached  to  the  bone 
and  covered  by  normal  or  thinned  skin  which  is  not  adherent,  is  quite 
characteristic.  Mistakes  in  diagnosis  should  not  be  made  when  a  num- 
ber of  these  tumors  are  situated  ujjon  the  bones  of  the  hands  and  feet, 
and  when  there  are  a 
number  of  cartilaginous 
exostoses  upon  tlie  met- 
aphyses  of  the  long 
bones.  Small,  isolated 
cortical  chcmdromas  re- 
semble exostoses,  but  X- 
ray  pictures  enable  one 
to  difi'erentiate  between 
them  (Fig.  310). 

Central  chondromas 
of  the  metaphyses  of  long 
bones  may  be  mistaken 
for  chronic  inflanniiatory 
foci  or  myeloid  sarcomas. 
Examination  with  the  X- 
rays  makes  a  differential 
diagnosis  possible.  The 
bone  surrounding  an  in- 
flammatory focus  becomes 
thickened  and  sclerotic, 
casting  a  heavy  shadow, 
while  bone  covering  a 
central  tumor  becomes 
expanded  and  thin,  cast- 
ing a  faint  shadow. 
Distinct,  bony  trabeculie 
may  be  seen  between 
the  different  nodules  or 
cysts  of  a  central  chon- 
droma, while  a  mye- 
loid sarcoma  casts  a 
shadow  of  the  same 
density  throughout  (Fig. 
313). 

Chondromas  of  the  soft  tissues  are  to  be  recognized  by  their  nodular 
form,  slow  growth,  distinct,  sharp  boimdaries  and  position.     Sometimes 


Fig.  316. — Enchokdrom.\s  .\.\d  Mxosto.ses  of  the 
LoAVER  Ends  of  thk  Boxes  of  the  Forearms.  The 
bonps  upon  the  right,  side  arc  shortened  and  deformed. 
Exostoses  may  also  be  seen  upon  the  thaphysis  of  each 
humerus. 


812  DIFFERENT   VARIETIES  OF   TUMORS 

it  is  impossible  to  differentiate  between  chondromas  occurring  in  the 
soft  tissues  and  mixed  tumors. 

Indications  for  Treatment — Technic. — Because  of  their  doubtful  char- 
acter, chondromas  should  be  removed  when  so  situated  that  the  oper- 
ation will  not  be  dangerous  or  mutilating.  Single  tumors  especially 
should  be  removed;  if  multiple,  only  those  which  grow  rapidly  or 
because  of  size  or  position  give  rise  to  symptoms. 

If  the  bone  involved  has  not  already  been  destroyed,  an  attempt 
should  be  made  to  enucleate  the  tumor,  preserving  the  continuity  of  the 
bone.  Parts  of  the  tumor  left  behind  after  enucleation  should  be  re- 
moved with  a  curette.  The  deep  cavities  remaining  in  the  bone  after 
removal  of  the  tumor  may  be  filled  with  ]Mosetig-Moorhoff's  bone  plug 
(p.  254). 

'  If  the  tumor  rapidly  recurs  from  pieces  left  at  the  previous  opera- 
tion or  from  previously  latent  germinal  tissue,  resection  of  the  diseased 
bone  may  be  indicated.  Resection  is  also  indicated  whenever  the  de- 
struction of  the  bone  has  been  extensive.  Amputation  of  the  fingers  or 
toes,  hand  or  foot,  is  often  necessary,  because  of  the  extensive  destruc- 
tion of  the  bones  caused  by  these  tumors.  Enchondromas  of  the  pelvic 
bones  may  become  so  large  that  they  are  inoperable. 


CHAPTER    IV 

OSTEOMAS 

Osteomas  are  tumors  composed  of  bone.  They  are  benign  tumors 
Avhich  in  their  development  may  repeat  periosteal  as  well  as  endochon- 
dral bone  formation,  and  consist  either  of  compact  (osteoma  durum  or 
eburneum)  or  spongy  bone  (osteoma  spongiosum),  or  contain  large 
spaces  filled  with  bone  marrow  (osteoma  medullosum).  Depending  upon 
their  origin,  the  surface  of  these  tumors  is  covered  with  periosteum  or 
cartilage  (periosteal  or  fibrous,  and  chondral  or  cartilaginous  osteomas). 

Relation  Between  Osteomas  and  Hyperplastic  Growths. — In  no  other 

(;lass  of  til IS  is  it  so  dillicult  to  make  a  sharp  distinction  between  true 

tumors  ill  1(1  hyperplastic  growths.  There  is  but  little  uniformity  of 
opinion  nmong  authorities  as  to  the  basis  upon  which  it  should  be  made. 
This  is  so  for  the  following  reasons:  (1)  Bone  is  peculiar  in  that  it 
reacts  rapidly  to  infiamiiiations  and  traumas  of  all  kinds,  proliferating 
to  form  tuniorlikc  gi-owtlis  up<m  the  surface  of  the  part  involved  (in- 
llammatory  and  ti"iumalic  exostoses)  ;  (2)  there^are  a  number  of  dis- 
eases of  bone,  such  as  osteitis  deformans  of  Paget,  osteitis  fibrosa  of 


OSTEOMAS 


813 


Recklinghansen,  leoiitiasis  ossea  of  Vircliow,  llic  cause  and  nature  of 
whieli  are  unknown  that  are  associated  with  the  formation  of  tumorlike 
growths  in  bone.  Bony  growths,  very  closely  resembling  tumors,  also 
develop  in  muscles.  (3)  A  number  of  hyperplastic  growths  which 
genetically  have  no  relation  whatever  to  osteomas  undergo  secondary 
ossification,  or  the  degenerated  areas  in  them  become  calcified,  so  that  it 
is  often  impossible  to  separate  them  from  true  tumors.  A  genetic  rela- 
tionship is  found  only  in  the  ossifying  fibromas  and  chondromas  which 
develop  from  osteal  tissues   (fi])roma  and  chondroma  ossificans). 

Most  Common  Site  for  Development. — Naturally  osteomas  are  most 
connnon  in  bone,  developing  mostly  as  exostoses  from  the  surface  of 
bone;  in  rare  cases  as  enostoses  from  their  interior. 

Exostoses. — Cartilaginous  exostoses  are  more  frequent  than  fibrous 
ones.  Composed  of  spongy  or  compact  bone,  they  occur  as  single  or 
nuiltiple  tumors,  often  at  a  num- 
ber of  different  points.  They 
may  be  congenital  or  acquired, 
or  may  develop  in  early  child- 
hood. They  grow  slowly  to  at- 
tain the  size  of  a  fist.  In  rare 
cases  they  become  larger,  form- 
ing hard  nodular  tumors  with  a 
broad  base  or  thin  pedicle.  They 
give  rise  to  no  symptoms  unless 
they  press  upon  adjacent  nerves 
or  become  so  large  that  they 
interfere  with  motion.  Some 
of  these  tumors  cease  growing 
when  the  individual  attains  full 
growth,  others  continue  to  grow 
slowly  but  steadily  even  after 
this  time. 

Most  Common  Sites  for  De- 
velopment.— They  are  most  com- 
mon in  the  long,  hollow  bones 
developing  near  the  articular 
ends  and  metaphyses.  An  exos- 
tosis which  developed  in  early 
life  is  gradually  displaced  into 
the  diaphysis  as  the  bone  increases  in  length.  Frequently  the  bones 
become  shortened  and  deformed;  congenital  defects  may  also  occur. 
Exostoses  are  also  found  on  the  ribs,  the  clavicle,  pelvic  bones,  and 
scapula;  rarely  on  the  bones  of  the  fingers  and  toes,  or  those  of  the 


Fig.  317. — Cartilagixous  Exostosis  of  the 
Femuh. 


814 


DIFFERENT   VARIETIES   OF   TUMORS 


skull  and  face.  In  other  words,  they  may  be  found  anywhere  in  the 
bony  system  where  cartilage  was  originally  present,  and  especially  in 
the  vicinity  of  the  epiphyseal  cartilages.  In  the  pelvis  they  are  most 
frequently  found  about  the  epiphyseal  cartilages  and  along  the  crest 
of  the  ilium;  on  the  scapula  they  occur  upon  the  anterior  surface  and 
along  the  axillary  border,  often  interfering  with  motion. 

Multiple  cartilaginous  exostoses  may  give  rise  to  a  peculiar  clinical 
picture.  They  may  be  associated  with  multiple  chondromas,  especially 
of  the  fingers,  and  with  different  anomalies  of  growth.  Only  one  case 
(Chiari)  which  has  been  complicated  by  the  development  of  a  sarcoma 
has  been  reported. 

Origin  of  Exostoses. — Cartilaginous  exostoses  develop  from  islands 
of  cartilage  which  have  been  displaced  as  a  result  of  defects  in 
the  skeletal  anlage  or  of  pathological   processes  occurring   during  the 

later  development  of  the 
bone.  The  frequent  mul- 
tiple occurrence  of  these  tu- 
mors, hereditary  transmis- 
sion, simultaneous  anoma- 
lies in  growth  supposedly 
due  to  the  same  cause, 
their  frequent  association 
with  chondromas  which  ge- 
netically are  the  same  and 
are  frequently  found  in 
one  member  of  the  family, 
while  exostoses  are  found 
in  the  other  members,  and 
finally  the  demonstration  of 
small  displaced  islands  of 
cartilage  near  by  the  exos- 
toses (von  Recklinghausen, 
Chiari)  all  point  to  this 
origin. 

Exostosis  Bursata. — The  exostosis  bursata  (von  Volkmann)  is  a  spe- 
cial form  which  is  situated  most  commonly  upon  the  lower  epiphysis 
of  the  femur  and  is  covered  by  a  bursa  similar  to  other  bursae  occur- 
ring abont  the  knee  joint.  The  bursa  is  finnly  attached  to  the  edges 
of  the  CMi-tilnginons  covering  of  the  nodular  growth  and  contains  a 
synovialike  fluid,  and  in  rare  cases  numerous  free,  cartilaginous  joint 
bodies.  "Slimy  regard  the  bursa  as  a  seeondnry  formation,  the  result 
of  long-continued  pressure  oi-  irritation  (von  Volkmann,  von  Reckling- 
hausen) ;  others  believe  that  during  the  development  of  the  exostosis 


Fig.  318. — Cartilaginous  Exostosis  of  the  Proxi- 
mal Phalanx  of  the  Third  Finger. 


OSTEOMAS 


815 


a  part  of  the  synovial  mcnibraiu'  of  the  joint  was  cva^inated  and  later 
became  constricted  to  form  a  distinct  bursa  (Rindlloisch)  ;  while  still 
others  believe  that  the  bursa  develops  from  a  portion  of  the  joint  anlage 
which  became  displaced  during  fa'tal  life  (Fehleisen). 

Diagnosis. — The  diagnosis  of  cartilaginous  exostoses  is  based  upon 
their  position  and  relation  to  the  bone,  their  slow  growth,  hardness,  and 
well-defined  borders.  The  clinical  picture  of  multiple  cartilaginous  ex- 
ostoses is  characteristic,  and  the  diagnosis,  as  a  rule,  should  be  made 
without  difficulties.  Single  tumors  may  be  confused  with  periosteal 
fibromas  and  chondromas  unless  one  makes  use  of  X-ray  pictures. 

Fibrous  Exostoses. — Fre([uently  fibrous  exostoses  cannot  be  difl'er- 
entiated  from  circumscribed  growths  of  bone  not  at  all  related  to  true 
tumors  ctiologically. 

Relation  to  In/!ammatio7i 
and  Trauma.  —  Infiannnation 
and  traumatism  often  stimu- 
late the  periosteum  to  the  for- 
mation of  large,  rapidly  grow- 
ing, bony  growths  (Ilonsell). 
Sometimes  tumorlike  processes 
develop  from  the  callus  follow- 
ing a  fracture  and  extend  be- 
tween the  neighboring  muscles, 
developing  apparently  from  ,  . 
separated  and  displaced  frag-  |1 
ments  of  periosteum.  Other  ex- 
ostoses develop  where  circum- 
scribed areas  of  periosteum  are 
subjected  to  constant  pressure 
(subungual  exostoses  of  the 
great  toe,  exostoses  npon  inner 
side  of  great  toe  in  hallux 
valgus),  and  still  others  de- 
velop where  tendons  or  mus- 
cles are  inserted.  They  appear 
as  roughened  areas,  bony  pro- 
jections and  crests. 

Of  the  bones  of  the  skull, 
the  frontal  and  parietal  are 
most  frequently  involved,  the 
exostoses  occurring  as  single  or 

multiple,  nipple  or  buttonlike,  spinous  and  pedunculated  tumors  cov- 
ered by  a  thin  layer  of  periosteuni.     They  may  be  situated  upon  the 


\ 


A 


Fig.  319.  —  Cartilaginous  Exostosis  ox  the 
Medial  Side  of  the  Uppeu  Metaphysis  of 
THE  Tibia  in  Genu  Valgim  Rhachiticum. 


816 


DIFFERENT   VARIETIES   OF   TUMORS 


internal  or  external  plate  of  these  bones  or  upon  both  plates,  opposite 
each  other.  The  exostoses  rarely  become  larger  than  a  walnut.  One 
of  the  larger  forms  is  represented  in  Fig.  322. 

Only  a  part  of  the  exostoses  of  the  orbit  and  the  different  cavities 
of  the  face  develop  from  periosteum,  as  the  osteomas  of  the  frontal  and 
sphenoidal  sinus  develop  from  foetal  rests  displaced  from  the  cartilagi- 
nous anlage  of  the  ethmoid   (Arnold).     If  these  tumors  fill  the  cavity 


1'"  Hi.  320. — Mri/i  iii.i;  ( 'Ainii. acinous  Exostosks  ok  the  Metaphysts  of  the  Femur  and 
TiiiiA  WITH  A  Chondroma  of  the  Upper  Metaphysis  of  the  Fibula  on  the  Right 
Side. 


ill  wliicli  they  lie,  they  are  called  "  encapsulated  homj  bodies  "  (Cru- 
V('illiiei-).  If,  as  a  result  of  suppuration  and  necrosis,  their  pedicle  is 
dcsti-oycd  and  the  connection  with  the  wall  of  the  cavity  is  lost,  they 
an'  called  "  dead  osteomas  "  (Tillmanns).  These  exostoses  grow  slowly, 
:ii!(l  i:i;idii;illy  produce  a  pressure  atroi)hy  of  the  walls  of  the  cavity 
ill  which  I  hey  lie,  extending  to  neighboritig  cavities  or  the  surface;  for 


OSTEOMAS 


817 


example,  from  the  frontal  sinus  to  the  forehead  or  into  the  orbit,  from 
the  sphenoidal  sinns  into  the  cranial  cavity. 

Osteomas  of  the  Jaws. — In  the  jaws,  not  including  the  encapsulated 
osteomas  of  the  antrum  of  Highmore,  there  are  found  periosteal  nodular 
exostoses  which  often  attain  consider- 
able size  and  central  tumors  surround- 
ing tooth  buds.  Only  a  part  of  the 
latter  are  pure  osteomas;  the  remain- 
der are  odontomas,  usually  composed 
of  dentine  and  developing  from  nor- 
mal or  displaced  teeth. 

Symptoms. — The  symptoms  depend 
upon  the  position  of  the  tumor  and 
the  direction  in  which  it  extends. 
Growing  from  the  under  surface  of 
the  skull  or  from  the  vertebnv,  they 
may    give    rise    to    serious    symptoms 

from  irritation  or  compression  of  the  brain  and  spinal  cord.  A  tumor 
developing  in  the  frontal  sinus,  by  occluding  the  eonununication  be- 
tween the   accessory  sinus  and  the  nose,  may   lead  to  sinus  inflamma- 


FiG.  321. — Subungual,  Exostosis. 


Fig.  322. — Enormous  Exostosis  of  the  Temporal  Bone,  Part  of  which  Projects  into 
THE  Skull  Cavity.     Sclerosis  of  the  boues  of  the  skull,     (von  Volkniaim.) 


818  DIFFERENT   VARIETIES  OF  TUMORS 

tion.  Tumors  may  also  be  so  situated  as  to  press  upon  important  nerves 
(optic  and  trigeminal)  or  to  cause  ugly  deformities  of  the  face. 

Diagnosis. — The  diagnosis,  because  of  the  slow,  painless  growth  and 
the  circumscribed  form  of  the  tumor,  or  of  the  symmetrical  expansion 
of  the  bone  in  osteomas  of  the  accessory  sinuses,  is  usually  not  difficult. 

In  the  beginning  they  may  resemble  clinically  central  sarcomas. 
When  an  empyema  of  the  frontal  or  maxillary  sinuses  develops  second- 
ary to  the  tumor,  the  inflammatory  symptoms  may  be  most  prominent. 
The  deep  shadow  which  an  osteoma  casts  in  X-ray  pictures  aids,  in 
doubtful  cases,  in  making  the  diagnosis.  The  bony  growths  occurring 
in  leontiasis  ossea  do  not  have  sharp,  distinct  outlines. 

Treatment. — The  treatment  consists  of  complete  removal  of  the  oste- 
oma when  possible.  Recurrences  may  develop  from  pieces  of  the  tumor 
which  are  left  behind. 

Myelogenous  Enostoses. — True  (myelogenous)  enostoses  of  the  long, 
hollow  bones  are  exceedingly  uncommon  (Virchow,  Bennecke).  Those 
developing  in  the  skull  bones  from  the  diploe  and  extending  outward 
and  inward  cannot  be  differentiated  from  exostoses  which  develop  on 
the  surface  and  later  perforate  the  bones   (von  Bergmann). 

Bony  Growths  in  Soft  Tissues. — Bony  growths  also  occur  in  the  soft 
tissues.  Even  in  these  cases  it  is  often  difficult  to  distinguish  between 
osteomas  proper  and  inflammatory  hyperplastic  growths  of  connective 
tissue  which  have  secondarily  undergone  calcification  and  ossification. 
Part  of  the  small  nodular  osteomas  of  the  brain,  of  the  flat  growths  in 
the  dura  mater  (falx  cerebri),  of  the  circumscribed  foci  occurring  in 
the  lungs,  of  the  multiple  small  nodules  and  cords  upon  the  inner 
surface  of  the  trachea,  and  of  the  bony  deposits  in  the  cavernous  tissue 
of  the  penis  (penis  bones)  develop  from  displaced  cartilaginous  rests. 
This  is  especially  true  of  the  osteomas  of  the  lung  and  trachea  which 
develop  from  the  cartilaginous  anlage  of  the  respiratory  passages. 

Myositis  Ossificans. — The  ossification  of  muscle  gives  rise  to  an  im- 
portant and  peculiar  clinical  picture.  Although  the  disease  may  be 
conveniently  discussed  in  this  chapter,  the  pathological  changes  are  not 
exactly  similar  to  those  resulting  in  the  formation  of  osteomas  in  soft 
tissues. 

This  disease  may  be  progressive,  affecting  in  succession  a  number  of 
different  muscles  {myositis  ossificans  progressiva),  or  limited  to  one 
muscle  {myositis  ossificans  cimcumscripta) ,  the  changes  following  a 
trauma. 

In  myositis  ossificans  progressiva  a  number  of  different  muscles 
gradually  change  into  Ixtnc.  In  some  of  the  cases  the  changes  begin 
in  the  periosteum  (Virchow)  leading  to  the  formation  of  exostoses  at 
the  point  of  attachment  of  the  muscle,  and  then  extend  to  the  connective 


OSTEOMAS 


819 


tissue  of  the  muscles  and  to  the  fascia.  In  other  cases  the  disease  begins 
in  the  bellies  of  the  nuiseles  (Lexer,  von  Zoe,u(^-]\Iantenffel,  Stenipel)  and 
extends  in  both  directions  to  their  points  of  attachment.  The  new  bone 
which  is  formed  may  become  attached  to  the  bones  at  the  point  of 
attachment  of  the  muscles  or  may  remain  free. 

Histological  CJiangcs  in  Myositis  Ossificans. — Histological  examina- 
tions made  in  the  early  stages  of  the  disease  (Lexer,  Stempel)  have 
revealed  germinal  tissue  rich  in  cells 
which  infiltrates  the  intermuscular  con- 
nective tissues  (perimysium  externum  and 
internum),  causing  a  pressure  atrophy 
of  the  muscle  fibers  and  bundles  which 
are  replaced  by  a  firm  connective  tissue 
or  bone,  repeating  in  its  development 
either  the  periosteal  or  endochondral 
type  of  bone  formation.  In  the  begin- 
ning of  the  cellular  growths,  round-cell 
infiltration,  a  change  indicative  of  in- 
flammation, may  be  observed. 

These  changes  have  some  relation  to 
the  clinical  picture,  but  cannot  be  re- 
garded as  either  the  cause  or  the  result 
of  the  process.  The  proliferation  extends 
from  the  perimysium  to  the  tissues  sur- 
rounding the  tendons  and  to  the  fasciae, 
and  both  become  ossified. 

Up  to  the  present  time  about  fifty 
cases  of  this  disease  have  been  observed. 
It  begins  in  early  life,  rarely  after  the 
twentieth  year,  and  is  about  three  times 
more  frequent  in  the  male  than  in  the 
female.  There  are  no  data  concerning 
heredity. 

Muscles  Most  Frequently  Involved 
and  Clinical  Course. — The  disease  usu- 
ally begins  in  the  muscles  of  the  neck 
and  back.  Suddenly  the  muscles  or 
groups  of  muscles  involved  swell  and  become  painful.  The  swelling 
is  sometimes  accompanied  by  fever  and  a  slight  reddish  or  bluish 
discoloration  of  the  skin  covering  the  muscles.  The  pain  following 
motion  and  pressure  gradually  subsides,  and  the  swollen  nmscles,  of  a 
doughy  consistency  at  first,  become  smaller  Jind  indurated.  This  stage 
has  been  called  by  Miinchmeyer  the  stage  of  connective-tissue  indura- 


FiG.  323. — Proghkssive  Ossifying 
Myositis  from  a  Photograph 
Owned  by  Professor  Helfer- 

ICH. 


820  DIFFERENT   VARIETIES  OF  TUMORS 

tion.  In  some  cases  the  patholo<,ncal  changes  do  not  progress  farther. 
In  the  majority  of  cases,  however,  the  changes  progress,  and  corallike, 
scalloped  cords  and  plates  of  bone  develop  throughout  the  muscle  pri- 
marily involved  and  extend  to  adjacent  muscles.  These  not  only  de- 
stroy the  function  of  the  muscles  involved,  but  fix  the  extremities  in 
uncomfortable  and  useless  positions,  as  the  newly  formed  bone  bridges 
over  the  joints,  uniting  bone  with  bone. 

A  number  of  years  may  intervene  between  attacks,  in  each  of  which 
new  muscles  are  involved.  Finally  the  entire  musculature  of  the  trunk, 
different  muscles  of  the  extremity,  and  the  nuiscles  of  mastication  may 
become  ossified.  The  patient  then  becomes  transformed  into  a  motion- 
less mass  (ossified  man).  Deglutition  and  respiration  gradually  become 
more  and  more  difficult,  and  finally  after  a  number  of  years  the  patient 
dies  of  exhaustion  or  of  aspiration  pneumonia. 

Cause  of  the  Disease. — There  has  been  a  great  deal  of  discussion 
as  to  the  cause  of  the  disease.  The  name  myositis  ossificans  has  been 
given  it  because  of  the  inflammatory  symptoms  in  the  muscles  at  the 
beginning  of  the  disease.  It  is  well  established  that  a  very  cellular 
germinal  tissue  develops  in  the  internuiscular  spaces  which  becomes 
transformed  into  dense  connective  tissue  and  bone.  It  has  been  sug- 
gested that  the  disease  is  the  result  of  a  congenital  anomaly  of  develop- 
ment in  the  skeletal  system,  or,  as  Stempel  thinks,  is  due  to  the  im- 
perfect differentiation  of  the  mesenchyme,  as  a  result  of  which  the 
muscles  acquire  the  property  of  forming  bone.  In  some  cases  mal- 
formations of  the  fingers  and  toes  (microdactylism,  anchylosis  of  the 
phalanges,  absence  of  the  terminal  phalanges  and  muscles)  have  been 
present  at  the  same  time  (Virchow,  Helferich),  supporting  the  view 
that  the  disease  is  a  congenital  anomaly  of  development. 

The  diagnosis  of  the  disease  may  be  difficult  at  the  beginning. 

Treatment. — Treatment  has  no  influence  whatever  upon  the  course 
of  the  disease.  The  patient  should  be  made  as  comfortable  as  possible, 
and  pieces  of  bone  which  interfere  with  motion  or  render  the  patient 
uncomfortable  (especially  bone  about  the  jaw  interfering  with  masti- 
cation and  about  the  joints)   should  be  removed. 

Myositis  Ossificans  Circumscripta. — Myositis  ossificans  circumscripta 
is  not  a  progressive  lesion.  It  follows  repeated  traumatisms  or  a  single 
severe  injury,  and  remains  limited  to  the  muscle  primarily  involved,  in 
which  histological  changes  (similar  to  those  described  above  in  myo- 
sitis ossificans  progressiva)  occur.  The  bony  plates  and  cords  which 
develop  lie  firmly  imbedded  in  the  connective  tissues  of  the  muscle  or 
become  fused  with  the  bone  at  its  points  of  attachment. 

The  so-called  rider's  bone  develops  in  the  adductor  muscles,  more 
rarely   in   the   pectineus   and   gracilis,    after   injuries   received   during 


OSTEOMAS  821 

horseback  riding;  the  so-called  exercise  bone  develops  in  the  deltoid 
muscle  after  injuries  caused  by  the  rifle  coming  forcibly  in  contact 
with  the  muscle  during  drill.  The  turner's  bone,  which  develops  in  the 
brachialis  anticus,  is  a  rarity.  The  development  of  bone  in  these  cases 
is  probably  due  to  some  congenital  anomaly  in  the  connective  tissues  of 
the  muscle,  as  the  result  of  which  they  acquire  the  property  of  forming 
bone  when  injured  or  irritated. 

The  ossification  of  muscle  following  a  single  trauma  (myositis  ossifi- 
cans traumatica)  gradually  develops  in  the  course  of  months.  The 
brachialis  anticus  and  quadriceps  extensor  muscles  are  most  frequently 
involved.  Lymph  cysts  may  also  develop  in  the  connective  tissues  sur- 
rounding the  piece  of  bone  (Wolter).  Myositis  ossificans  traumatica 
follows  severe  contusions,  dislocations,  and  fractures,  and  cannot  be  sepa- 
rated from  those  bony  growths  which  extend  from  an  exuberant  callus 
into  the  soft  tissues.  The  bone  probably  develops  in  these  cases  from 
separated  and  displaced  fragments  of  periosteum. 

The  position  of  the  bone  in  a  muscle  which  is  exposed  to  repeated 
traumas  or  has  been  severely  contused  suggests  at  once  the  diagnosis. 
The  findings  may  be  readily  verified  by  an  X-ray  picture.  [Gouty 
deposits  in  muscles  and  about  joints  are  sometimes  confusing.] 

Although  cases  have  been  observed  in  which  the  bone  disappeared 
spontaneously  and  in  which  massage  has  been  helpful,  extirpation  with 
subsequent  suture  of  the  wound  in  the  muscle  is  to  be  recommended 
if  there  are  symptoms. 

Literature. — v.  Bcrgmann.  Geschwiilste  tier  Schiidelknocken.  Handb.  d.  prakt, 
Chir.,  2.  Aufl.,  Bd.  1,  p.  123. — Bennecke.  Exostose  der  Tibia.  Zentralbl.  f.  Chir., 
1904,  p.  500. — Bornhaupt.  Ein  Fall  von  linksseitigem  Stirnhohlenosteom.  Arch, 
f.  klin.  Chir.,  Bd.  26,  1881,  p.  589. — Busse  and  Blecher.  Ueber  Myositis  ossificans. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  73,  1904,  p.  388. — Chiari.  Ziir  Lehre  von  den  multiplen 
Exostosen  (mehr  als  1,000  Exostosen  und  ein  Spindelzellensarkom  am  Humerus). 
Prager  med.  Wochenschr.,  1892,  No.  35. — Eckert.  Zur  Kenntnis  der  Osteoma  des 
Unterkiefers.  Beitr.  z.  klin.  Chir.,  Bd.  23,  1899,  p.  674. — Fehleisen.  Zur  Kasuistik  der 
Exostosis  bursata.  Arch.  f.  klin.  Chir.,  Bd.  33,  1886,  p.  152. — Honsell.  Ueber  trau- 
matische  Exostosen.  Beitr.  z.  klin.  Chir.,  Bd.  22,  1898,  p.  277. — Lexer.  Das  Stadium 
der  bindegewebigen  Induration  bei  Myositis  ossificans  progressiva.  Arch.  f.  klin.  Chir., 
Bd.  50,  1895,  p.  1. — Nadler.  Myositis  ossificans  traum.  mit  spontanem  Zuriickgang 
der  Muskelverknocherung.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  74,  1904,  p.  427. — Nasse. 
Ueber  multiple  kartilaginare  Exostosen  und  multiple  Enchondrome.  v.  Volkmanns 
Samml.  klin.  Vortrage,  No.  124,  1895. — Reich.  Ein  Beitrag  zur  Lehre  iiber  die  multiplen 
Exostosen.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  43,  1896,  p.  128. — Ricthus,  Exost.  bursata 
mit  freien  Knorpelkorpern.  Beitr.  z.  klin.  Chir.,  Bd.  37,  1903,  p.  639. — Rothschild. 
Ueber  Myositis  ossificans  traumatica.  Beitr.  z.  klin.  Chir.,  Bd.  28,  1900,  p.  1. — Schider. 
Ueber  traumatische  Exostosen.  Beitr.  z.  klin.  Chir.,  Bd.  33,  1902,  p.  556. — Stark. 
Ueber  multiple  kartilaginare  Exostosen  und  deren  klinische  Bedeutung.  Beitr.  z. 
klin.  Chir.,  Bd.  34,  1902,  p.  508. — Stempel.  Die  sogenannte  Myositis  ossificans  pro- 
gressiva.    Mitteil.   aus  d.  Grenzgeb.,   Bd.   3,    1898. — Virchow.     Ueber   Myositis  ossi- 


822 '"       "*  DIFFERENT   VARIETIES  OF  TUMORS 

ficans  progressiva.  Verhandl.  der  Berl.  med.  Gesellsch.,  1894,  I,  p.  172  and  II,  p.  142 
and  1900,  I,  p.  151. — Walter.  Ueber  Myositis  ossificans  traumatica  mit  Bildung  von 
Lymphzys'  en.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  64,  1902,  p.  351. — v.  Zoege-Manteuffel. 
Demonstration  eines  Skelettes  mit  Myositis  ossificans.  Chir.-Kongr.  Verhandl.,  1896, 
I,  p.  43. 


CHAPTER    V 

ANGIOMAS 

HEMANGIOMAS 

The  tumoi-s  composed  of  abnormally  arranj^ed,  tortuous,  and  dilated 
vessels  are  classified  as  angiomas.  The  term  angioma,  however,  should 
be  applied  to  those  tumors  only  in  which  there  is  an  actual  new  forma- 
tion of  vessels  or  a  proliferation  of  the  vessel  walls,  aneurysms  and 
varicose  veins  being  thus  excluded.  Angiomas  composed  of  blood  vessels 
(hannangiomas)  are  distinguished  from  those  composed  of  lymphatic 
vessels  ( lymphangiomas ) . 

Three  forms  of  ha?mangioma  are  distinguished :  IIa?mangioma  sim- 
plex, cavernosum,  and  racemosum. 

Haemangioma  Simplex. — The  haaiiangioma  simplex  is  also  known  as 
a  telangiectasis.  This  term,  however,  does  not  fully  describe  the  nature 
of  the  tumor,  as  there  is  not  only  "  a  dilatation  of  the  vessels,"  but 
an  actual  new  formation  of  vessels  as  well.  During  the  removal  of  such 
a  growth  small,  dark-red,  spurting  lobules  may  be  seen  at  the  edge  of 
the  tumor.  These  are  held  together  by  connective  tissue,  and  may 
extend  close  to  the  epidermis  or  be  covered  by  a  thin  layer  of  the  cutis 
and  reach  into  the  surrounding  fatty  tissues,  muscle,  and  fasciae.  Not- 
infrequently  these  growths  are  surrounded  by  a  delicate  connective- 
tissue  capsule  which  is  united  with  the  neighboring  structures  only  at 
the  points  where  the  vessels  enter  and  leave  the  growth. 

The  tumor  is  composed  of  dilated,  interlacing  capillaries  and  small 
vessels,  the  walls  of  which  contain  fiat  or  cubical  endothelium  and  cir- 
cularly arranged  connective-tissue  bundles.  If  both  the  endothelium 
and  connective  tissue  have  proliferated  (angioma  simplex  hyperplasti- 
cum  of  Virchow)  and  the  lumina  of  the  vessels  have  become  narrow 
as  a  result,  it  is  often  difficult  to  differentiate  the  vessels  from  sweat 
Jirid  st'baccous  glands,  both  of  which  may  be  found  in  these  tumors. 
'I'lic  Iransfoniiatioii  of  llie  vessels  into  solid  cords  consisting  of  pro- 
liferated emlol  IkTiuiii  roriiis  a  transitional  stage  to  the  luemangio-endo- 
theliomas. 

Augi(mias  aic  jiot  inl'i'f(piently  eoinbiiied  with  other  forms  of  tumors 


ANGIOMAS 


823 


of  the  comieetive-tissiie  group,  forming  angiolipomas,  angiofibromas, 
angiosarcomas,  etc. 

Simple  ha'inaiigiomas  enlarge  in  the  following  way :  the  processes 
developing  from  the  vessels  extend  like  buds  into  the  snrrounding  tis- 
sues, and  by  a  con- 
tinuous new  forma- 
tion and  dilatation 
of  the  capillaries 
the  adjacent  tissues 
become  completely 
infiltrated.  This 
method  of  growth, 
which  resembles  the 
infiltrating  growth  of 
malignant  tumors, 
leads  to  the  destruc- 
tion of  the  infiltrated 
tissue,  even  if  it  is 
bone.  They  never 
form  metastases, 
however,  and  do  not 
enlarge  in  this  way 
if  encapsulated.    The 

growth,  sometimes  glow,  at  other  times  rapid,  is  frequently  interrupted 
for  long  intervals  or  ceases  permanently  after  a  short  time.  Secondary 
changes  following  inflammation  may  cause  complete  involution. 

Simple  ha?mangionias  are  the  result  of  developmental  anomalies. 
According  to  Ribbert,  the  area  supplied  by  a  small  artery  develo])s  from 
the  beginning  without  any  connection  with  surrounding  tissues,  or  loses 
its  connection  during  subsecjuent  growth  and  develops  independently. 
The  facts  emphasized  by  Virchow  that  angiomas  are  conunonly  situated 
about  the  lips,  cheeks,  eyelids,  and  the  root  of  the  nose,  the  position  of 
earlier  fo4al  clefts,  and  that  tliey  are  frequently  congenital  and  often 
nuiltiple  support  this  theory. 

Simple  haemangionias  dcA'elop  most  commonly  in  the  skin  and  sub- 
cutaneous tissues.  xVlthough  any  part  of  the  body  may  be  involved, 
two  thirds  of  these  tumors  occur  in  the  skin  of  the  face. 

Cutaneous  Angiomas. — The  cutaneous  angiomas  may  be  present  at 
birth,  appearing  as  light-red  or  dark-red,  well-defined,  round,  or  scal- 
loped blotches  or  elevations,  or  they  may  develop  during  the  first  few 
weeks  or  months  of  life  from  small,  scarcely  noticeable  points  (resem- 
bling a  flea  bite)  from  which  little  delicate  vessels  radiate  (nanais  vas- 
culosus,  'flannueus,  port-wine  mark).     Some  of  these  nipvi  grow  very 


Fi:-,.  324. — HEMANGIOMA  Simplex  Cutis. 


824 


DIFFERENT   VARIETIES  OF  TUMORS 


rapidly,  extending  within  half  a  year  over  the  entire  half  of  the  faee; 
others  enlarge  slowly,  their  growth  corresponding  to  that  of  the  body. 
Not  infrequently  the  veins  of  the  surrounding  tissues  become  dilated. 

If  the  tumor  also  extends  into  the  deeper  tissues,  nodular,  polypoid, 
and  lobulated  masses  of  dark-red  color  covered  by  a  delicate  skin  de- 
velop which  resemble  the  changes  {vide  p.  793)  found  in  elephantiasis 
(elephantiasis  hffimangiectatica) . 

Sudcutaneons  Angiomas. — The  subcutaneous  appear  later  than  the 
cutaneous  angiomas,  remaining  concealed  beneath  the  skin  until  the  lat- 
ter becomes  thin  enough  to  allow  the  bluish  shimmer  to  show  through. 
A  distinct  swelling  produced  by  filling  of  the  vessels,  when  the  patient 
cries,  or  the  principal  vessels  are  pressed  upon  and  the  circulation  inter- 
fered with,  and  the  extension  of  the  growth  to  the  epidermis  leading  to 
the  formation  of  red  blotches  and  elevations  as  in  cutaneous  angiomas 
indicate  the  presence  of  these  tumors. 

If  both  the  skin  and  subcutaneous  tissues  are  involved,  pads  and 
folds  form  upon  the  flat  surface  of  the  angioma  from  which,  especially 
upon  the  lips,  lids,  and  nose,  large,  purple,  blackberrylike,  lobulated, 
and  pedunculated  tumors  may  develop  (Fig.  326).    These  tumors  contain 

parts  which  are  transitional  to 
the  cavernous  angiomas. 

A  simple  angioma  occurring 
upon  the  lips  may  produce  a 
macrocheilia  similar  to  that 
caused  by  a  lymphangioma.  The 
upper  lip,  which  is  more  fre- 
quently involved,  then  hangs 
down  as  an  irregular  bluish  fold 
over  the  mouth,  while  the  lower 
lip  when  involved  projects  out- 
ward like  a  snout.  The  tumor 
enhirges  when  the  patient  stoops, 
cries,  or  becomes  excited.  It  has 
been  said  of  Emperor  Leopold, 
that  when  angry  his  lip,  the 
seat  of  such  a  growth,  hung 
down  to  his  chin. 

Angiomas  of  the  eyelid,  which 
may  be  primary  in  these  struc- 
tures  or   extend  to  them   from 
the    temporal    and    naso-frontal 
regions,  should  Ix-  ineiilioned,  as  they  may  invade  the  orbit  and  threaten 
llie  iiileurily  of  the  eye. 


Fia.  325.— SiMi'i 


Ci  1. 


AND     SlUK'UTA- 


NEOUS    HEMANGIOMA. 


ANGIOMAS 


825 


Simple  Miigioiiias  of  the  sealp,  according  to  Ileineeke,  comprise  thirty- 
thi'ee  per  cent  of  the  angiomas  of  the  liead.  They  oeeiir  most  freciuently 
ill  the  frontal  region,  tleveloping  about  the  ghil^eUa,  at  tlie  inner  ex- 
tremity of  the  eyebrow,  and  over 
the  fontanelles. 

Changes  WJiich  May  Occur  in 
an  Angioma. — The  most  impor- 
tant changes  which  may  occur  in 
a  simple  angioma  are  inflamma- 
tion, haemorrhages,  and  sponta- 
neous involution.  It  has  often 
been  observed  that  not  only  the 
small,  but  also  the  larger  flat  an- 
giomas may  completely  or  par- 
tially disappear  following  the 
obliteration  of  the  vessels  com- 
posing them. 

Frequently  inflammation,  which 
develops  after  an  injury  of  the 
thin,  easily  vulnerable  skin,  pre- 
cedes and  favors  subsequent  ul- 
ceration, cicatrization,  and  oblit- 
eration of  the  vessels.  It  has 
occasionally    been    attempted    to    ^ 

.  .  -^  .  Fig.  32(i. — Si.mi'i.i:  I.ohulated  Hemangioma. 

cure  angiomas  in  children  by  in- 
fecting them.     Haemorrhages  are  not  frequent.     When  they  occur  they 
are  apt  to  be  profuse,  but  may  easily  be  controlled  by  a  bandage  exert- 
ing mild  pressure. 

Simple  angiomas  are  also  found  in  rare  cases  in  fat,  especially  in 
that  of  the  orbit,  in  muscles,  the  breast,  in  bone,  the  brain,  and  spinal 
cord.  The  small,  macular,  and  wartlike  ha?mangiomas,  never  becoming 
larger  than  a  pea,  which  occur  as  multiple  growths  upon  the  surface 
of  the  body  associated  with  soft  and  pigmented  warts,  form  a  special 
grou}).     'i'liey  develop  usually  in  old  age. 

Haemangioma  Cavernosum. — The  cavernous  angioma  (ha^mangioma 
eavernosum)  resembles  in  structure  the  corpus  cavernosum,  being  com- 
posed of  retiform  blood  spaces.  Frequently  transitional  stages  to  the 
cavernous  ha-mangioma  are  found  in  the  simple  hannangioma,  from 
which  they  may  develop.  The  irregular  cavities,  flUed  with  blood  and 
communicating  with  each  other,  are  surrounded  by  a  network  of  fibrous 
tissue  containing  elastic  tlbers.  The  thickness  of  the  network  varies  in 
ditferent  parts  of  the  tumor.  These  tumors  are  nourished  by  a  single 
artery  and  discharge  their  blood  into  dilated  veins.  Thrombosis  of  the 
53 


826 


DIFFERENT   VARIETIES  OF  TUMORS 


blood  spaces  leads  to  localized  connective-tissue  clianf^es.  If  the  thrombi 
become  calcified,  phleboliths  are  formed.  Single  spaces  may  become 
closed  and  transformed  into  blood  cysts  in  this  way.  These  tumors 
may  be  well  encapsulated  or  the  capsule  may  be  entirely  or  partly 
absent,  and  then  the  tumor  extends  without  any  sharp  line  of  demarca- 
tion into  the  surrounding  tissues.  The  growth,  as  in  simple  angiomas, 
may  be  partly  expansive,  partly  infiltrating,  slow  but  continuous,  or 
rapid  after  remaining  stationary  for  some  time.  An  encapsulated 
tumor  frequently  ceases  to  grow.  Involution  may  be  complete  after 
thrombosis  and  cicatricial  contraction  of  parts  of  the  tumor. 

The  fact  that  these  tumors  are  frequently  congenital  and  multiple 
indicates  that  they,  like  simple  angiomas,  are  the  result  of  some  develop- 
mental anomaly,  the  exact  nature  of  which 
is  unknown. 


Fig.  327. — Cavernous  Hemangioma  of  the  Subcuta- 
neous Fat  (After  Extirpation). 


Fig.   328. — Cavernous   H.em- 
angioma  of  the  Ear. 


Most  Common  Sites  for  Development. — These  tumors  develop  most 
frequently  in  the  skin  and  subcutaneous  tissues,  being  most  common  in 
the  cheeks,  eyelids,  lips,  and  scalp.  Other  parts  of  the  body  are  more 
rarely  involved  and  with  about  the  same  frequency.  These  tumors, 
which  may  be  present  at  birth,  oi*  develop  shortly  after,  more  rarely  in 
later  life,  assume  a  number  of  different  forms.  Cavernous  angiomas 
of  the  skin  are  characterized  by  the  formation  of  dark-blue,  bluish- 
black,  nipplelike,  and  nodular  growths,  or  of  largo,  blackberrylike,  lobu- 
lated  masses  covered  by  a  delicate  epidermis;  cavernous  angiomas  of 
the  subcutaneous  tissues  by  the  formation  of  a  flat  swelling,  covered 
by  slightly  bluish,  discolored,  otherwise  normal  skin,  or  by  skin  the 
seat  of  a  simple  haemangioma  or  nipplelike  growths,  such  as  are  asso- 
ciated with  cavernous  hfemangiomas  of  the  skin.  If  both  occur  together, 
folds  in  skin,  such  as  are  found  in  elephantiasis  (elephantiasis  caver- 
nosa), m;iy  (h-vcloj).    ('iivci'iioiis  ha-inatigiomas  of  the  cheeks,  eyelids,  and 


ANGIOMAS  827 

lips  soon  extend  to  the  mucous  membranes,  forming  bluish  nodules  and 
lobulated  growths. 

Cavernous  angiomas  of  the  face  frequently  assume  rapid  growth, 
extending  from  the  cheek  to  the  mucous  membranes  of  the  mouth  cavity 
and  lips,  finally  involving  the  entire  half  of  the  face  and  head.  If  they 
occur  in  the  scalp,  the  spongy  tissue  composing  the  tumor  may  grow 
through  the  bones  and  become  connected  by  means  of  dilated  emissary 
and  larger  veins  with  the  venous  sinuses.  Excruciating  pain  may  be 
produced  if  the  tumor  presses  upon  nerves,  especially  upon  the  branches 
of  the  trigeminal  nerve.  A  cavernous  angioma  of  the  orbit  may  dis- 
place the  bulb  of  the  eye  and  threaten  its  integrity. 

It  should  be  mentioned  that  these  tumors  occur  in  the  tongue  and 
occasionally  in  the  different  muscles  (muscles  of  the  calf,  rectus  ab- 
dominis, sterno-cleido-mastoid,  and  masseter). 

Of  the  abdominal  viscera,  the  liver  is  most  frequently  the  seat  of 
cavernous  tumors,  occurring  as  small,  multiple  growths  which  are  acci- 
dentally found  during  post-mortem  examinations.  Sometimes  they  ap- 
pear as  large,  occasionally  pedunculated,  tumors,  especially  in  children. 
Cavernous  tumors  may  also  occur  in  the  spleen,  bone  marrow,  uterus, 
and  intestines,  but  are  very  rare. 

Ha?morrhage,  following  rupture  of  nodules  covered  by  thin  skin, 
may  be  quite  profuse,  but  is  easily  controlled  by  a  bandage  exerting 
mild  pressure  and  by  cauterization. 

Diagnusis. — The  diagnosis  of  hemangiomas,  the  simple  as  well  as 
the  cavernous,  is  based  upon  their  peculiar  color  and  form  and  upon 
the  fact  that  they  can  be  emptied  by  pressure,  but  refill  when  the  pres- 
sure is  removed.  The  soft  tumor  masses,  nodular  if  thrombi  or  phlebo- 
liths  are  present,  become  smaller  and  less  discolored  when  pressure  is 
exerted,  but  rapidly  fill  with  blood,  assuming  their  original  form  and 
color  as  soon  as  the  pressure  is  released.  In  tumors  of  the  dependent 
portions  of  the  body  the  increase  in  size  is  very  noticeable  when  pres- 
sure is  exerted  upon  the  veins  passing  from  the  tumor,  or  when  the 
patient  stands  up.  After  compression  of  a  subcutaneous  angioma  of  the 
scalp,  the  pits  and  fissures  in  the  bone  through  which  the  dilated, 
anastomosing  veins  pass  to  the  interior  of  the  skull  may  be  easily  felt. 
Only  the  deep-lying,  calcified,  or  mixed  tumors  (lipoangioma)  do  not 
decrease  in  size  upon  pressure.  Cavernous  hamiangiomas  may  pulsate 
if  nourished  by  large  arteries.  The  clinical  picture  of  angiomas  is  char- 
acteristic, and  the  diagnosis  usually  not  difficult.  Sometimes  it  is  dif- 
ficult to  differentiate  the  isolated,  subcutaneous  forms  from  other  tu- 
mors, especially  when  there  is  no  involvement  of  the  skin.  It  is  not 
difficult  to  exclude  plexiform  angiomas,  aneurysms,  and  varicose  veins 
if  the  symptoms  are  pronounced. 


828  DIFFERENT   VARIETIES  OF  TUMORS 

Treatment. — There  are  a  number  of  methods  which  may  be  employed 
in  the  treatment  of  simple  and  cavernous  angiomas. 

Superficial  and  deep  angiomas,  when  encapsulated,  should  be  excised. 
If  the  tumor  is  situated  upon  the  extremities,  haemorrhage  should  be 
controlled  during  the  operation  by  elastic  constriction ;  if  situated  upon 
other  parts  of  the  body,  by  digital  compression  or  special  instruments. 
If  the  tumor  is  not  encapsulated  and  extends  into  the  deeper  tissues, 
the  greater  part  of  it  should  be  rapidly  removed  with  a  sharp  spoon 
(von  Bergmann),  for  after  the  large  blood  spaces  are  destroyed  there 
is  but  little  haemorrhage  from  the  small  arteries  entering  the  tumor 
tissue.  Large  defects  should  be  skin-grafted  or  closed  by  plastic  oper- 
ations. 

Deep  angiomas  of  the  face  extending  through  the  cheek  to  the  mu- 
-cous  membrane,  and  angiomas  which  perforate  the  bones  of  the  skull 
should  not  be  excised.  In  treating  angiomas  in  young  children,  the 
bloodless  methods  are  always  to  be  preferred  when  they  can  be  em- 
ployed. In  the  treatment  of  superficial  birthmarks,  a  single  applica- 
tion of  fuming  nitric  acid  is  a  simple  and  effective  method.  The  eschar 
produced  by  this  acid  extends  deeply  enough,  and  when  it  is  cast  off 
a  delicate  scar  remains.  The  skin  surrounding  the  angioma  should  be 
protected  from  the  acid  by  adhesive  plaster  or  some  other  device. 

Puncturing  with  the  actual  cautery  (ignipuncture)  is  often  success- 
fully employed  in  the  treatment  of  elevated  nodular  na?vi,  which  should 
never  be  excised  when  occurring  in  weak  children.  It  may  be  necessary 
to  repeat  ignipuncture  a  number  of  times,  as  the  tumor  cannot  be 
destroyed  by  one  application  without  leaving  unsightly  deformities,  and 
it  recurs  from  the  tissue  which  is  not  destroyed  unless  the  treatment  is 
repeated  after  an  interval.  The  scars  resulting  from  this  treatment  are 
large  and  unsightly,  and  therefore  this  method  cannot  be  employed  for 
angiomas  of  the  face.  Aseptic  dressings  should  be  applied  after  sepa- 
ration of  the  eschar  to  prevent  secondary  infection,  for  infections  devel- 
oping in  hamiangiomas  of  the  cheek  or  scalp  may  easily  extend  to  the 
meninges.  Payr,  after  making  small  incisions  in  the  skin,  has  inserted 
small  pieces  of  magnesium  into  the  tumor  in  all  directions.  As  the 
metal  is  being  absorbed  the  blood  coagulates,  the  large  dilated  vessels 
become  occluded,  and  even  deep  extensive  tumors  sometimes  disappear. 
This  method  is  especially  suited  for  the  treatment  of  inoperable  haem- 
angiomas  of  the  skull  and  face. 

The  injection  of  chemicals  sometimes  cause  a  gradual  obliteration 
of  the  vessels  and  reduction  in  the  size  of  the  tumor.  Alcohol  has  been 
I'cconuiMMKh'd  by  Sclivvalbe.  From  fifteen  to  sixty  drops  of  seventy  or 
eighty  per  cent  alcohol  are  injected  at  first  into  the  margins,  later 
directly  into  the  tumor,  some  days  intervening  between  each  injection. 


ANGIOMAS 


829 


The  injections  shonld  not  he  mnAe  where  the  shin  is  thin,  as  it  may 
b<'C<)ine  necrotic,  favorinj^-  ha'niorrha<ivs  and  infection,  [ivepcated  injec- 
tions of  small  quantities  (1  to  2  c.c.)  of  boiling  water  with  a  hypo- 
dermic needle  and  syringe  directly  into  the  angioma  offers  one  of  the 
best  methods  of  treatment.] 

Some  of  the  flat  and  superficial  ha-mangiomas  have  been  successfully 
treated  by  the  X-rays  (vide  p.  774). 

The  Cirsoid  Aneurysm. — The  cirsoid  angioma  (cirsoid  aneurysm,  an- 
gioma arteriale  racemosum  of  Virehow)  consists  of  thickened,  dilated, 
tortuous  pulsating  vessels,  the  ^r^^ 

arteries  supplying  the  tumor 
emptying  directly  into  large 
blood  spaces  without  the  in- 
tervention of  capillaries.  The 
dilatation  of  the  vessels  may 
be  fusiform  or  saccular.  Fre- 
quently the  afferent  artery  is 
thickened  for  a  considerable 
extent  as  the  result  of  pro- 
liferation of  its  walls,  while 
the  efferent  veins,  communi- 
cating as  they  do  directly 
with  the  artery,  are  trans- 
formed into  large,  pulsating 
cords.  For  this  reason  this 
form  of  angioma  is  frequently 
referred  to  as  a  phlebarteriec- 
tasia. 

Cirsoid  angiomas  develop 
most  frequently  from  sim- 
ple, congenital  ha^mangiomas. 
They  also  develop  after  fre- 
quently repeated  mechanical 
injuries  (e.  g.,  after  pulling  the  ears,  Konig)  after  injuries  of  the  hand 
received  while  rowing,  after  a  single  trauma,  and  even  without  any 
apparent  cause. 

It  is  probable  that  this  form  of  new  growth  is  the  result  of  some 
congenital  defect  in  the  arterial  anlage,  as  a  result  of  which  the  tissues 
composing  the  artery  may  be  stimulated  to  proliferation  by  a  number 
of  different  influences. 

Most  Common  Sites. — Cirsoid  angiomas  occur  most  frequently  in  the 
scalp  and  face,  more  rarely  in  the  extremities,  the  arm  (hand  and  fore- 
arm) being  next  most  frequently  involved. 


Fig.  329. — Cirsoid  Aneurysm  of  the  Face  which 
WAS  NOT  Improved  by  Ligation  of  the  Ex- 
ternal Carotid  Artery  and  Other  Large 
Branches  Supplying  it  and  by  the  Injec- 
tion  of  Alcohol. 


830 


DIFFERENT   VARIETIES  OF  TUMORS 


The  superficial,  tortuous,  auglewormlike  strands  and  masses  are  cov- 
ered by  a  thin,  cyanotic  skin  which  is  fre([uently  adlierent  at  a  number 
of  different  points. 

When  they  occur  in  the  face,  the  skin  covering  the  tumor  is  fre- 
quently the  seat  of  a  simple  angioma,  or  is  raised  to  form  a  flat  swelling. 


Fig.  330. — Cirsoid  Aneurysm  of  the  Hand  and  Forearm 
'  (Englebrecht's  Preparation). 

which  gradually  disappears  into  the  surrounding  tissues.  The  vessels 
composing  the  tumor  pulsate,  the  pulsations  being  transmitted  to  the 
skin.    Rhythmical  impulses  and  thrills  may  be  felt  when  the  angioma  is 

palpated ;  loud  blowing  and  buzz- 
ing bruits,  transmitted  to  com- 
municating vessels,  may  be  heard 
when  the  tumor  is  auscultated. 
In  angiomas  of  the  extremities 
these  signs  disappear  when  pres- 
sure is  made  upon  the  principal 
arteries.  This  does  not  always 
occur  in  the  face,  because  the 
anastomosing  arteries  are  more 
numerous ;  frequently,  however, 
a  slowing  and  strengthening  of 
the  pulse  can  be  noticed,  ap- 
parently the  result  of  the  di- 
version of  the  blood  into  the 
general  circulation  following  the 
exclusion  of  so  large  a  circula- 
tory area. 

Clinical  Course  and  Regressive 
Changes. — These  tumors  develop 
(piite  rapidly  at  first;  later  more 
slowly,    growth    often    being   in- 
terrupted   l)y    long   intervals.      When    they    occur   iq)on    the    head    the 
patient  often   coiiiijlains  of   headache  and   dizziness;   throbbing   of  the 
head    and    ringing    m    ijic    (.;irs,    preventing    sleep;    excruciating    pain 


Fig.  331. — Racemose  H-emangioma  of  the 
Scalp  (von  Langenbeck's  Collection). 


ANGIOMAS  831 

caused  by  pressure  upon  the  nerves,  and  funetional  disturbances, 
the  result  of  adhesions  between  the  tumor  and  adjacent  nerves  and 
muscles. 

Necrosis  of  the  atrophic  skin  covering  these  growths  is  a  serious 
matter,  as  chronic  ulcers  favoring  ha'mori'hage  and  infection  then 
develop.  Even  the  terminal  phalanges  of  the  fingers  may  become  ne- 
crotic when  the  tumor  involves  the  hand. 

Diagnosis. — The  diagnosis  of  cirsoid  aneurysm  is  not  difficult,  as  the 
appearance  of  the  tumor  composed  of  anglewormlike,  tortuous,  pul- 
sating vessels  is  quite  characteristic.  It  can  scarcely  be  mistaken  for 
any  other  lesion. 

Treatment. — Treatment  is  veiy  unsatisfactory.  The  ideal  method, 
complete  extirpation  w^ith  ligation  of  the  principal  artery  and  in- 
numerable smaller  ones,  is  fre<iuently  impracticable,  because  of  the 
size  of  the  growth.  Ligation  of  the  principal  artery  alone  has  given 
no,  or  only  transitory,  results.  In  cirsoid  aneurysm  of  the  extremi- 
ties this  procedure  is  even  dangerous,  because  of  the  possibility  of 
gangrene. 

In  a  male  patient  with  an  extensive  cirsoid  angioma  of  the  left  side 
of  the  face,  whose  picture  is  reproduced  in  Fig.  329,  all  the  large,  acces- 
sible arteries  surrounding  the  tumor,  such  as  the  external  carotid,  the 
facial,  the  large  branches  of  the  temporal,  and  the  angular  at  the  inner 
canthus  of  the  eye,  were  ligated  M'ithout  success. 

Injection  of  chemicals  with  the  object  of  causing  thrombosis,  and 
later  cicatricial  contraction,  is  not  at  all  successful  in  these  cases.  In 
the  patient  mentioned  above,  numerous  injections  of  alcohol  were  made 
without  any  success.  This  method  is  even  dangerous,  as  thrombi  may 
become  separated  and  carried  into  the  large  dilated  veins  leaving  the 
growth,  causing  fatal  embolism. 

Cauterization  should  be  entirely  discarded,  as  severe,  even  fatal 
haemorrhage  may  follow  separation  of  the  eschar. 

Amputation  may  be  indicated  when  tumors  of  this  character  situated 
upon  the  extremities  become  ulcerated,  leading  to  frequent  and  profuse 
httmorrhages,  and  when  phlegmons  develop,  as  incisions  cannot  be  made 
into  these  growths. 

LYMPHANGIOMAS 

Lymphangiomas  are  much  more  uncommon  than  luvmangiomas. 
They  appear  in  three  principal  forms,  between  which  are  many  transi- 
tional stages. 

Lymphangioma  Simplex. — The  simple  lymphangioma  (lymphangioma 
simplex)  corresponds  to  the  simple  Immiangioma,  as  it  develops  from  a 
proliferation  of  the  lymphatic  vessels  of  a  limited  area  of  the  skin  and 


832  DIFFERENT   VARIETIES  OF  TUMORS 

subcutaneous  tissues.  The  connective  tissues  lying  between  the  newly 
formed  vessels  usually  proliferate  to  form  a  part  of  the  tumor.  These 
tumors  occur  in  the  form  of  congenital,  flat,  or  slightly  nodular,  but 
little  circumscribed  thickenings  of  the  skin  of  the  face  and  neck,  and 
are  to  be  regarded  as  true  tumors.  Transitional  stages  between  the 
simple  and  cavernous  forms  are  frequently  found.  Lymphangiectases 
developing  after  chronic  inflammations  and  associated  with  the  diffuse 
hyperplasias  of  connective  tissues  occurring  in  elephantiasis  are  to  be 
differentiated  from  simple  lymphangiomas  {vide  Figs.  240  and  241,  pp. 
649  and  651).  Lymphangioma  tuberosum  cutaneum  multiplex  (Kaposi) 
occurring  in  the  form  of  yellowish-brown  nodules,  never  becoming  larger 
than  a  lentil,  which  may  be  scattered  throughout  the  skin  of  the  entire 
body,  also  apparently  belongs  to  the  lymphangiectases. 
,  Lentigines,  Freckles,  Flesh  Warts,  etc. — The  endothelium  lining  the 
lympliatic  vessels  may  proliferate,  filling  completely  the  lumina  of  the 
vessels.  New  growths  develop  in  this  way  which  should  be  classified 
with  endotheliomas.  Ziegler  classifies  a  number  of  pathological  changes 
occurring  in  the  skin,  such  as  pigmented  ncevi,  lentigines,  freckles,  and 
flesh  warts,  commonly  known  as  hypertrophic  lymphangiomas,  with  en- 
dotheliomas. All  these  have  this  in  common — they  are  composed  of 
round  collections  or  cordlike  masses  of  proliferated  endothelial  cells  of 
the  lymphatic  vessels  lying  in  a  connective-tissue  reticulum.  Borst  be- 
lieves that  connective-tissue  proliferation  predominates  in  the  pigmented 
nffivi  (therefore  the  term  fibroma  melanodes),  while  Soldan  has  shown 
that  part  at  least  of  the  pigmented  n^evi,  like  soft  warts,  are  connected 
witli  the  cutaneous  nerves  (vide  p.  328). 

Lymphangioma  Cavernosum. — The  lymphangioma  cavernosum  is  the 
most  common  form  of  the  diffuse,  non-encapsulated  lymphangiomas.  It 
is  of  congenital  origin,  or  develops  in  later  life  from  congenital  begin- 
nings, and  occurs  in  the  skin,  subcutaneous,  and  intermuscular  con- 
nective tissues.  Histologically  it  resembles  quite  closely  the  cavernous 
hfpmangioma,  as  the  tumor  is  composed  of  irregular  spaces  filled  with 
lymph  and  eomnninicating  with  each  other.  These  spaces  are  lined  by 
endothelium  and  are  surrounded  by  a  meshwork  of  fibrous  tissue  con- 
taining smooth  muscle,  elastic  fibers,  and  small  lymph  nodes.  A  part 
of  tiie  lymphatic  vessels  of  the  normal  surrounding  structures  com- 
municate with  the  spongy  tissue  of  the  tumor,  so  that  when  pressure  is 
made  the  tumor  gradually  decreases  in  size,  and  regains  its  normal  size 
again  when  the  pressui'e  is  removed. 

Most  Common  Sites  and.  Clinical  Course. — Cavernous  lymphangio- 
mas occur  most  frequently  in  the  cheeks  (l)eing  occasionally  bilateral), 
in  the  tongue,  lips,  eyelids,  and  lateral  regions  of  the  neck.  The  new 
growths  may  aj)pear  in  the  following  different  forms; 


ANGIOMAS 


833 


^^   ^h'    ^' 


^ 


'-) 


1.  In  the  cheeks  (macromelia,  Fig.  332)  and  nock,  as  flat,  loose  swell- 
ings, covered  by  normal,  yellowish,  or  reddish  skin  which  cannot  be 
raised  from  the  tumor. 
The  tumor  gradually  be- 
comes continuous  with 
the  normal  surrounding 
tissues. 

2.  As  nodular,  some- 
times transparent,  tu- 
morlike thickenings  of 
the  lips  (macrocheilia), 
concha  {vide  Fig.  333), 
and  eyelids. 

3.  As  unshapely  en- 
largements of  the  tongue 
(macroglossia.  Fig.  334), 
which  becomes  rigid  and 
protrudes  from  the 
mouth,  and  as  lobulat- 
ed  growths  of  consider- 
able size  (elephantiasis 
congenita  lymphangiec- 
tatica)  of  the  face  and 
neck,  the  subcutaneous  tissues  also  being  involved.  Encephaloceles  and 
myeloceles  not  infrequently  lie  concealed  beneath  lymphangiomas,  de- 
veloping over  the  places  where  these 
malformations  occur.  Lymphangio- 
mas of  the  mucous  membranes  of  the 


Fig.   332.- 


-Mackumelia   Caused  by  a  Congenital  C.vv- 
ERNOus  Lymphangioma. 


Fk;.  333. — CoxcENiTAL  Cavernous 
Lymphangioma  of  the  Ear. 


Fig.  334. — L'iTWPHANoioMA  (n  im  i  i  i  (Ma- 
croglossia), AS  Seen  Under  a  Magnifying 
Glass. 


pharynx  and  soft  palate  sometimes  appear  as  soft,  red  elevations.    These 
at  times  become  inflamed,  and  as  the  inflammation  is  accompanied  by 


834 


DIFFERENT   VARIETIES  OF   TUMORS 


fever,  a  diagnosis  of  diphtheria  may  he  made,  especially  if,  as  in  a  case 
observed  by  Suckstorff,  a  membrane  forms  as  a  result  of  the  coagulation 
of  lymph  discharged  from  the  tumor. 

The  slow  growth  is  continuous,  but  may  be  interrupted  by  rapid 
increase  or  decrease  in  size,  due,  especially  in  lymphangiomas  of  the 
face,  to  infection  with  bacteria  entering  from  the  mucous  membranes 
(Tavel).  This  rapid  increase  and  decrease  in  size  is  common  to  the 
clinical  picture  of  all  lymphangiomas.  The  cavernous  tissue  infiltrates 
the  skin  and  sends  out  conelike  processes  between  the  muscles,  displacing 
and  surrounding  nerves  and  blood  vessels.  Cases  have  been  observed 
in  which  even  bone  has  been  destroyed  by  these  growths  (Katholicki). 

Diagnosis. — The  diagnosis  of  a  cavernous  lymphangioma  may  be 
based  upon  the  poorly  defined  margins  of  the  tumor,  its  soft,  relaxed 
consistency,  indistinct  fluctuation,  compressibility,  varying  in  different 
parts  of  the  tumor,  and  upon  its  being  covered  by  skin  which  is  not 
adherent  and  but  little  discolored. 

Lymphangioma  Cysticum. — This  form  of  lymphangioma  is  much  more 
frequently  encapsulated  than  the  cavernous,  even  the  processes  extend- 
ing into  adjacent  tissues  being  surrounded  by  a  capsule.  The  sharp 
boundaries  are  wanting  only  in  the  transitional  forms  which  contain 
cavernous  tissue.  The  cystic  lymphangioma  consists  of  single  or  mul- 
tiple cysts,  varying  in  size  from  a  pinhead  to  a  child's  head.     The  cysts 

contain  a  serous  fluid 
^^j'^'>><;^<--;;JI  which,  after  injury, 
may  be  mixed  with 
blood.  The  cysts  do 
not  communicate  with 
neighboring  lymphat- 
ics, and  do  not  be- 
come smaller  on  pres- 
sure. Their  inner  sur- 
faces are  lined  with 
endothelium,  and  the 
walls  consist  of  thick 
fibrous  tissue  ar- 
ranged in  the  form 
of  a  cavernous  mesh- 
work. 

These  tumors  de- 
velop in  the  lateral 
regions  of  tlie  neck,  posterior  to  the  sterno-cleido-iiiastoid.  about  the 
angle  of  the  jaw,  or  in  the  supraclavicular  fossa,  and  extend  as  they 
enlarge  to  the  posterior  part  of  the  neck  and  toward  the  median  line. 


.•'v'v--. 


/ 


\' 


-:>>/'- 


1  1. 


('^>ll(      AM)    (tl)    ('AVl:UN()r 


I  ,Y!\irHAN(;i()MA. 


ANGIOMAS 


835 


A  large,  cystic  lymphangioma  may  oxIfMid  fi-om  llie  jaw  to  llie  clavicle, 
from  the  median  line  in  I'l'ont  to  tlie  same  line  j)osteriorly  (  Fig.  1386). 
The  new  growths,  depending  upon  the  amount  of  thiid  they  contain, 
may  be  elastic  and  fluctuating,  covered  by  skin  which  is  tense  l)ut  not 
adherent,  or  relaxed  and  soft.  When  the  walls  of  the  cysts  are  relaxed, 
irregularities  produced  l)y  ledgelike  projections  and  thickenings  may  be 
palpated.  As  they  enlarge,  cystic  lymphangiomas  may  exert  pressure 
upon  the  trachea,  a'sophagus,  and  large 
vessels,  and  become  dangerous.  This  is 
especially  so  when  they  enlarge  sud- 
denly as  the  result  of  intiammation, 
which  may  end  in  suppuration. 

Cystic   lymphangiomas    occur    more       /l§'fi  "^"^sSW  i^ 

rarely  in  the  cheeks,  axil- 
lary fossa,  groin,  and  upon 
the  flexor  surfaces  of  the 
extremities.  These  tumors 
are  occasionally  found 
upon  the  anterior 
surface  of  the  sa- 
crum and  in  the  root  . ' 
of  the  mesentery. 
The  latter  contain 
chyle.  The  diagnosis 
of  the  nature  of 
multilocular  cysts, 
occurring  where 
lymphangiomas  are  common,  is  not  difficult.  It  is  often  extremely  diffi- 
cult to  make  an  accurate  diagnosis  of  the  small  unilocular  forms,  as  one 
has  also  to  consider  branchial  and  blood  cysts  when  they  occur  in  the 
neck,  echinococcus  cysts  and  lipomas  when  they  occur  in  the  cheek. 

Varicosities  of  the  lymphatic  vessels,  developing  in  areas  with  a 
rich  lymphatic  supply,  give  rise  to  much  the  same  clinical  picture  as 
do  multilocular  lymphangiomas.  These  tumors  occurring  about  the 
sacrum,  must  be  differentiated  from  dermoid  cysts  and  teratoid  tumors; 
at  the  root  of  the  mesentery,  from  a  number  of  different  kinds  of 
cysts. 

Origin  of  Lymphangiomas. — Lymphangiomas  are  almost  exclusively 
of  congenital  origin.  They  are  the  result  of  a  disturbance  in  embryonic 
development,  being  frequently  associated  with  other  anomalies,  such  as 
myeloceles,  encephaloceles,  etc.  Not  only  the  lymphatic  vessels,  but  also 
the  fatty  and  fibrous  tissues  and  the  smooth  nuisculature  of  the  walls 
of  the  larger  lymphatics,  participate  in  these  growths  (Ribbert). 


I 


^'^Jl. 


••'."f*. 


Fig.  336. — C'uMii.Mi.vL,    Cvsnc    J>i.\iiiiA.\.,ny.\iA    i^t'vsTic   IIy- 
GROMA  OF  THE  Neck).     Cured  by  extirpation. 


836 


DIFFERENT   VARIETIES  OF  TUMORS 


Changes  Which  May  Occur  in  Lymphangiomas. — Lymphanpomas  are 
benign  growths,  notwithstanding  the  fact  that  they  fre(iuently  are  not 
encapsulated  and  may  be  so  situated  or  become  so  large  that  they 
threaten  life.  Inflammation  may  be  followed  by  cicatricial  contraction 
and  spontaneous  cure.  It  may  also  lead  to  the  most  serious  conse- 
quences, such  as  exhausting  lymph  fistulas  or  the  extension  of  the  in- 
flammation along  the  lymphatic  vessels  communicating  with  the  tumor, 
causing  phlegmon  of  the  orbit,  mediastinitis,  meningitis,  etc.,  depending 
upon  the  position  of  the  growth. 

Indications  for  Treatment  and  Technic. — Encapsulated  cystic  tumors 
should  be  extirpated.  If  the  skin  is  adherent  to  the  tumor  it  should  be 
removed  at  the  same  time.  If  one  proceeds  slowly  and  cautiously,  fre- 
quently the  entire  tumor  with  all  its  processes  may  be  removed  by  blunt 
dissection  (sponges  and  tissue  forceps)  without  rupturing  it.  Separa- 
tion of  adherent  nerves  offers  the  greatest  difficulties.  Cavernous  por- 
tions of  a  tumor  can  never  be  com- 
pletely removed. 


Fig.  3.37. — Specimen  Removed  from  Patient  Represented  in  Fig.  336. 


After  removal  of  the  tumor  the  wound  should  be  accurately  sutured 
and  a  compression  dressing  applied,  the  accumulation  of  lymph  and  the 
development  of  lymph  fistula>  being  prevented  in  this  way. 

Incision  of  the  c.yst  and  tamponade,  recommended  by  Wolfler,  should 
not  be  employed,  as  Nasse  has  shown  that  there  is  danger  of  infection 
which  may  persist  indefinitely  if  this  melhod  is  employed. 

The  simple  and  cavernous  lymphangiomas  cannot  be  radically  re- 
moved, and  even  partial  I'enioval  by  cuneiform  excision,  as  recommended 


ANGIOMAS  837 

in  the  treatment  of  macroglossia  and  maerocheilia,  is  not  without  dan- 
ger, as  lymph  fistiihv  and  progressive  inflammation  may  develop.  In 
the  treatment  of  these  eases,  especially  in  children,  one  must  be  content 
with  less  efficient  but  less  dangerous  methods,  such  as  the  injection  of 
alcohol,  tincture  of  iodin,  and  one  per  cent  solution  of  zinc  chlorid.  If 
frequently  repeated  they  cause  at  least  a  cicatricial  contraction  of  parts 
of  the  tumor  and  a  decrease  in  size.  Cauterization  should  be  discarded, 
as  it  has  the  same  disadvantages  as  the  incomplete  operation. 

Literature. — v.  Bramann.  Ueber  Chyluszysten  des  Mesenterium.  Arch.  f.  klija. 
Chir.,  Bd.  35,  1887,  p.  201. — Engelbrecht.  Angioma  arteriale  raceiiiosuni.  Arch.  f. 
kliii.  Chir.,  Bd.  55,  1897,  p.  347. — Fr.  Fischer.  Krankheiten  der  Lyinphgefasse,  Lymph- 
driisen  und  Blutgefasse.  Deutsch  Chir.,  1901,  Rankenangiom,  p.  222. — Heine.  Ueber 
Angioma  arteriale  racemosum.  Vierteljahrsschr.  f.  prakt.  Heilkuiule,  1869. — Hilde- 
brund.  Ueber  multiple  kavernose  Angioine.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  30, 
1889,  p.  91. — Honsell.  Ueber  Alkohohnjektionen  bei  inoperablen  Angiomen.  Beitr. 
z.  klin.  Chir.,  Bd.  32,  1902,  p.  251. — Katholicki.  Ein  Fall  von  Lymphangiom  des 
Vorderarmes.  Chir.  Kongr.-Verhandl.,  1903,  I,  p.  61  and  Diskuss.,  p.  125,  Payr,  v. 
Bramann. — A.  Kruse.  Ueber  das  Chylangioma  cavernosum.  Virch.  Arch.,  Bd.  125, 
1891,  p.  488.— Kiittner.  Ueber  die  intermittierende  Entziind.  d.  Lymphangiome. 
Beitr.  z.  klin.  Chir.,  Bd.  18,  1897,  p.  728.— Laewen.  Ueber  genuine  diffuse  Phlebar- 
teriektasie  a.  d.  ob.  Extremitat.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  68,  1903,  p.  364.— 
Lieblein.  Ueber  einen  durch  Alkohohnjektionen  geheilten  Fall  von  Angioma  racemo- 
sum des  Kopfes.  Beitr.  z.  klin.  Chir.,  Bd.  20,  1898,  p.  27. — E.  Miiller.  Zur  Kasuistik 
der  Lymphangiome.  Beitr.  z.  khn.  Chir.,  Bd.  1,  1885,  p.  498. — H.  Midler.  Ein  Fall 
von  arteriellem  Rankenangiom  des  Kopfes.  Beitr.  z.  klin.  Chir.,  Bd.  8,  1892,  p.  79. 
— W.  Midler.  Zur  Technik  der  Operation  grosserer  Hiimangiome  und  Lymphangiome. 
Beitr.  z.  klin.  Chir.,  Bd.  37,  1903,  p.  565. — Muskatello.  Ueber  das  primare  Angiom 
der  willkiirlichen  Muskeln.  Virch.  Arch.,  Bd.  135,  1894,  p.  277. — Narath.  Ueber 
retroperitoneale  Lymphzysten.  Chir.  Kongr.-Verhandl.,  1895,  II,  p.  396. — Nasse. 
Ueber  Lymphangiome.  Arch.  f.  klin.  Chir.,  Bd.  38,  1889,  p.  614. — Pmjr.  Ueber 
Verwendung  von  Magnesium  zur  Behandlung  von  Blutgefiisserkrankungen.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  63,  1901,  p.  503. — Ranke.  Zur  Anatomic  der  sercisen  Wang- 
enzysten.  Arch.  f.  klin.  Chir.,  Bd.  22,  1878,  p.  707.— Ribbcrt.  Wachstum  und 
Genese  der  Angiome.  Virch.  Arch.,  Bd.  151,  1898,  p.  381. — Rielhus.  Ueber  primare 
Muskelangiome.  Beitr.  z.  klin.  Chir.,  Bd.  42,  1904,  p.  454. — Ritschl.  Ueber  Lymph- 
angiome der  quergestreiften  Muskeln.  Beitr.  z.  klin.  Chir.,  Bd.  15,  1896,  p.  99. — 
RotUjans.  Aneurysma  cirsoides.  In  Hildebrand's  Jahresber.,  1897,  p.  346. — Sachs. 
Die  von  den  Lymphgefassen  ausgehenden  Neubildungen  am  Auge.  Zieglt-r's  Beitr. 
z.  pathol.  Anat.,  Bd.  5,  1889,  p.  99. — Samter.  Ueber  Lymphangiome  der  Mund- 
hohle.  Arch.  f.  klin.  Chir.,  Bd.  41,  1891,  p.  829. — Strauch.  Intranuiskularcs  kavernoscs 
Angiom  (Masseter).  Deutsche  Zeitschr.  f.  Chir.,  Bd.  62,  1902,  p.  'S2:i.—Suckstorff. 
Lymphangiom  des  Rachens  mit  Bildung  krupposer  Membranen.  Beitr.  z.  klin.  Chir., 
Bd.  27,  1900,  p.  185. — -Sutter.  Beitr.  zu  der  Frage  von  den  primiiren  Muskelangiomen. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  76,  1905,  p.  368. — Tavel.  Ueber  die  schubweise  auftre- 
tende  entzimdliche  Schwellung  der  Lymphangiome.  Zentralbl.  f.  Chir.,  1899,  p.  817. — 
Weichselbaum.  Chylangioma  cavernosum  des  Mesentcriums.  Virch.  Arch.,  Bd.  64, 
1875,  p.  145. — Wegner.  Ueber  Lymphangiome.  Arch.  f.  klin.  Chir.,  Bd.  20,  1877, 
p.  641. 


8.'?8 


DIFFERENT   VARIETIES  OF  TUMORS 


CHAPTER   VI 


SARCOMAS 


ii/'. 


;VjvSj 


Definition  and  Nature. — Sarcomas  (from  the  Greek  o-ap^,  meaning 
flesh)  are  malignant  tumors  which  are  derived  from  mesoblastic  tissues. 
They  are  composed  of  immature,  unripe  elements,  while  the  benign  con- 
nective-tissue tumors,  such  as  the  fibromas,  chondromas,  and  osteomas 
described  in  the  preceding  chapters,  are  composed  of  mature,  fully  devel- 
oped elements.  In  sarcomas  the  cellular  elements  predominate  over  the 
intercellular  substance,  the  former  proliferating  rapidly  and  without  re- 
straint. Sarcomas  are  closely  related  to  embryonal  tissues  and  to  granu- 
lation tissue  developing  in  wounds  and  in  chronic  inflammat-ory  processes 

(especially  the  infectious 
granulomas).  The  cells 
composing  the  latter, 
however,  comi:>lete  their 
cycle  of  development 
forming  adult  connective 
tissues  if  favorable  condi- 
tions are  provided,  while 
the  cells  composing  a  sar- 
coma maintain  their  em- 
bryonal characteristics. 
They  have  lost  their  abil- 
ity to  form  tissues  of  an 
adult  type  (Borst)  and 
proliferate  without  re- 
straint at  the  expense  of 
the  organism.  These  tu- 
mors form  the  malignant  group  of  the  connective-tissue  tumors  corre- 
sponding to  carcinomas,  malignant  tumors  arising  in  epithelial  tissue. 

Classification. — Sarcomas  differ  in  histological  characteristics  and  in 
their  clinical  courses.  Frequently  it  is  impossible  to  determine  the  clin- 
ical peculiarities  of  a  sarcoma  by  histological  findings;  therefore  it  is 
difficult  to  make  a  classification  in  which  both  the  histological  picture  and 
the  clinical  course  are  taken  into  consideration.  Ribbert's  classification 
seems  to  be  the  best.     He  distinguishes  between  sarcomas  composed: 

1.  Of  cells  of  any  of  the  connective  tissues; 

2.  Of  cells  rcsembliiig  lymph  corpuscles; 
.'1  Of  mucoid  tissues; 

4.  Of  pigment  cells. 


:),'^:-'.yj:<{.:^> 


Fig.  338. — Fibrosarcoma. 


SARCOMAS 


839 


Characteristics  Common  to  all  Sarcomas. — There  are  certain  charac- 
teristics conunoii  to  ail  sarcomas  wliicli  may  be  more  marked  in  some 
than  in  others. 

Sarcomas  consist  principally  of  cellular  elements,  the  intercellular 
tissue,  if  present,  beino^  greatly  reduced  in  amount.  The  intercellular 
substance  may  be  fibrillar,  cartilaginous,  bony,  or  nuicoid,  depending 
upon  the  origin  of  the 
tumor.  Remnants  of  tin 
infiltrated  and  degenerat- 
ing tissues  may  also  bt 
found  between  the  cells 
Blood  vessels,  the  develop- 
ment of  which  varies  in 
different  tumors,  form 
tliird  constituent  pai 
sarcomas.  As  in  granu- 
lation tissue,  the  ncA..,,  t >>-«'■'/"- 
formed  capillaries  form  f^^^^^-'' 
the  framework  for  the 
proliferating  groups  and 
columns  of  cells.  Among 
the  thin-walled  vessels,  ar- 
teries and  veins  cannot  be 

differentiated  from  each  other.  The  vessels  consist  of  spaces  or  clefts 
in  the  tumor  tissues.  In  some  cases  the  endothelium  lining  the  vessels 
rests  directly  upon  the  tumor  cells,  while  in  other  cases  the  connective- 
tissue  stroma  of  the  tumor  forms  a  fairly  well-defined  wall.  If  these 
spaces,  surrounded  by  stroma,  become  filled  with  cells,  struetui"es  histo- 
logically resembling  alveoli  (alveolar  .sarcoma)   are  produced. 

If  the  vessels  are  numerous  and  the  proliferation  of  the  tissues  im- 
mediately adjacent  to  them  is  marked,  transitional  stages  to  the  peri- 
theliomas, in  which  the  proliferation  begins  in  the  perivaseulnr  endo- 
thelial cells,  are  found.  This  is  especial)}^  true  if  the  columns  of  cells 
surrounding  the  vessels  do  not  become  fused  with  each  ollu  r.  l)iit  remain 
separated  by  intercellular  substance,  lymph,  or  blood,  'i'lu'se  tumors 
are  called  angiosarcomas  or,  better,  telangiectatic  or  cavernous  sarcomas 
(Borst),  as  these  terms  can  also  be  used  for  peritheliomas. 

Mode  of  Growth. — The  growth  is  usually  expansive  in  the  beginning, 
the  adjacent  displaced  tissues  forming  a  thin  capsule.  If  oi)erated 
upon  at  this  stage,  the  tumor  can  sometimes  be  easily  enucleated.  INIany 
sarcomas  from  the  first,  and  all  later  on.  infiltrate  the  surrounding  tis- 
sue, replacing  the  normal  structures.  Thc^  increase  in  size  of  these 
tumors  is  due  to  the  proliferation  of  the  cells  composing  them,  and  not 


Fig.  339. — Large  Spindlk-Ckll  Sarcoma. 


g40  DIFFERENT   VARIETIES  OF   TUMORS 

to  tlie  transformation  of  snrronnding  elements  into  tumor  tissue.  Pro- 
liferation of  the  surrounding  tissues  is  indicative  of  reactive  growth 
and  not  of  transformation  into  tumor  tissue.  The  infiltrated  tissues 
gradually  undergo  pressure  atrophy.  Pressure  upon  the  larger  vessels 
may  cause  necrosis.  Even  bone  is  disintegrated  by  the  tumor  cells. 
Cartilage  resists  their  growth  for  a  long  time. 

Regressive  Changes. — A  number  of  regressive  changes,  such  as  fatty 
and  parenchymatous  degeneration  of  the  cells,  necrosis  of  large  areas, 
hemorrhages,  thrombosis  of  the  large  vessels,  hyaline  degeneration  and 

obliteration    of    the    blood 


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S-I '   •* '  *"'*•.'■  ^  ■  '.•  ^Z-*" •  ^^"•V  ■*  ' 

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*"-■  ^^^'^::j*iJ^^^i^, 

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mm 

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p 


vessels  and  death  of  the 
tissues  surrounding  them, 
may  occur  in  any  sarcoma. 
Softened  areas  and  blood 
cysts  then  develop,  and 
^  1  upon  section  yellowish, 
gelatinous,  and  ha?mor- 
rhagic  foci  may  be  seen 
upon  a  surface  which,  in 
the  beginning,  is  of  a  gray- 
ish or  red  color  through- 
out. Necrosis  of  the  infil- 
trated skin  leads  to  the 
formation  of  deep  ulcers 
in  which  putrefactive  in- 
flannnation  may  easily  de- 

FiG.  340. — Round-Celi.  Sarcoma  of  the  Skin.  Velop.      It   is   interesting   tO 

note  that  these  tumors  oc- 
casionally become  smaller  following  an  attack  of  erysipelas  (Busch), 
the  cells  undergoing  a  fatty  degeneration  and  being  absorbed  (Spronck, 
Boi-st).     X-rays  have  a  similar  effect  upon  the  tumor  cells. 

Metastases. — The  malignancy  of  sarcomas  is  indicated  especially  by 
the  foi'ination  of  metastases.  The  tendency  to  the  formation  of  metas- 
tatic growths  is  least  mark(Hl  in  the  encapsulated  tumors  and  in  the 
relatively  highly  developed  fibrosarcomas;  it  is  most  marked  in  the 
cellular,  rapidly  growing,  infiltrating  forms,  especially  in  the  round- 
cell  sarcomas.  Secondary  nodules  may  develop  by  way  of  the  lymph 
stream  in  tissues  adjacent  to  the  tumor  or  in  regional  lymph  nodes. 
Metastases  by  way  of  the  lymphatics  are  not,  however,  the  rule  as  in 
carcinoma.  In  sarcomas  metastases  by  way  of  the  blood  stream  are 
more  eoiinnoii,  a.s  the  cells  invade  the  vessels  of  the  surrounding  tis- 
sues or  tliose  of  the  tumor  itself.  A  progressive,  intravascular  growth 
then    (l<'vel()j»s,    or,    ;is    Jiiore    frequently    happens,    a    small    group    of 


SARCOMAS 


841 


cells  or  sinofle  cells  are  separated  and  carried  away  in  the  blood 
stream  to  be  deposited  in  tlie  lun^s,  liver,  spleen,  bone  marrow,  the 
kidneys,  and  in  other  viscera  and  tissues.  The  metastatic  urowths 
repeat  the  structure  of  the  primary  tumor,  but  proliferate  still  more 
rapidly. 

Fever  and  Ansemia  Associated  with  Sarcomas. — The  effect  of  the  sar- 
coma upon  the  organism  is  often  indi(;ated  by  an  irregular  fever,  due  to 
the  absorption  of  pyrogenic  substances  from  the  tumor  (ha'morrhages, 
products  of  decomposition),  and  by  a  progressive  anaemia,  which  always 
suggests  the  formation  of  gcnei'al  metastatic  growths. 

Age  at  Which  Sarcoma  Develops. — Sarcomas  occur  most  commonly 
in  middle-aged  people,  more  rarely  in  the  young  and  old.  Congenital 
sarcomas  are  relatively  connnon.  It  is  striking  that  they  are  most 
common  in  powerful,  healthy  men.  As  a  rule,  the  primary  tumor  is 
single,  but  primary  multiple  tumors  have  been  observed. 

Cause  of  Sarcoma  Formation. — The  essential  cause  of  sarcoma  for- 
mation has  not  been  determined.  There  are  a  number  of  objections 
which  may  be  raised 
against  the  parasitic 
theory.  There  are 
a  number  of  facts 
which  seem  to  jus- 
tify the  theory  that 
these  tumors  arise 
from  rests,  displaced 
during  embryonal  or 
later  life,  such  as: 
their  congenital  oc- 
currence ;  the  pres- 
ence of  sarcoma  tis- 
sue in  (teratoid) 
mixed  tumors,  which 
certainly  develop 
from  tissue  displaced 
during  embryonal 
life ;  the  development 
of  tumors  from  dis- 
placed adrenal  rests,  Fig.  341.— .s..i.t,  \  as<i  i.ah  Sakcoma  of  the  Left  Half  of 
from       undescended  '^"^  Face,  Developing  Apparently  from  the  Hulu  of  the 

-      ...      ,  -,     .      .■  Eye.      The  growth  lias  extended  into  the  nose,  pharynx  and 

and   displaced    testi-      .  ^^qu,), 
cles,  and   from   con- 
genital tumors,   such   as  neurofibromas   and  soft   warts;   likewise,   the 
development  of  bone  and  cartilage  in  sarcomas  of  the  soft  tissues  and 
54 


842 


DIFFERENT  VARIETIES  OF  TUMORS 


the  occasional  development  of  sarcoma  tissue  in  any  of  the  benign 
connective-tissue  tumors.  Germinal  tissue  apparently  may  be  disiolaccd 
in  later  and  as  well  as  in  embryonal  life,  during  growth,  in  infiannna- 
tory  and  regenerative  processes   (Ribbert). 

A  sarcoma  developing  in  a  callus  following  a  fracture  may  be  cited 
as  an  example  of  a  tumor  developing  from  tissues  displaced  during 
regenerative  j)rocesses.  According  to  clinical  experience,  it  is  highly 
probable  that  the  trauma  is  only  the  exciting  cause  in  such  a  case, 


Fig.  342. — Sarcoma  Tissue  (a)  which  has  Invaded  Muscle  (b). 

stimulating  a  tumor  to  more  rapid  growth,  which  has  previously  ex- 
isted, but  has  given  rise  to  no  symptoms.  In  the  example  cited  above 
it  is  more  probable  that  a  tumor  existed  before  the  fracture  than  that 
a  tuiiioi-  developed  from  the  callus. 


(a)  SARCOMAS   DEVELOPING   FROM   THE   DIFFERENT 
CONNECTIVE   TISSUES 

Sarcomas,  which  develop  from  any  of  the  connective  tissues,  may 
contain  but  little  interstitial  substance  and  resemble  closely  histologic- 
ally embryonal  connective  tissues.  Some  of  these  tumors  contain  car- 
tilage and  bone,  indicating  that  they  have  developed  from  the  skeleton 
(chondi'o-  and  osteosarcoma). 


SARCOMAS 


843 


FIBROSARCOMAS 

Sarcomas  arising  from  fibrous  tissues  are  most  commonly  composed 
of  spindle  cells  (sarcoma  fusocellulare) ,  loss  frequently  of  round  cells 
(sarcoma  globocellu- 
lare),  small  and  large 
cells  with  many  tran- 
sitional forms  being 
found.  Besides  the 
soft,  medullary  forms, 
which  usually  are 
very  malignant,  there 
are  the  firm,  less  ma- 
lignant forms  contain- 
ing relatively  large 
amounts  of  intercellu- 
lar tissue.  The  dif- 
ferences in  consist- 
ency and  appearance 
depend  usually  upon 
the  number  of  blood 
vessels,  the  amount  of 
blood  pigment,  upon 
haemorrhages  and  re- 
gressive changes. 
Sometimes  the  cut  sur- 
face has  a  homogeneous,  grayish  red  or  dark  red  appearance;  at  other 
times  it  is  dotted  with  ha'morrhagic  foci  and  cysts. 

Histology  of  Fibrosarcoma. — The  spindle  cells  have  nuclei  centrally 
situated,  and  each  end  of  the  cells  is  provided  with  a  long  process.  The 
large  cells  are,  as  a  rule,  irregular  in  shape,  being  round  or  fusiform, 
oval  or  serrated.  Often  they  are  arranged  in  a  fasciculated  manner. 
The  intercellular  fibrilke  are  most  abundant  in  the  fibrosarcomas,  which 
can  only  be  differentiated  from  fibromas  by  their  cells  of  unequal  size, 
rich  in  cytoplasm  and  containing  large  nuclei. 

Spiiidle-ccll  sarconuis  usually  are  firm,  hard  tumors.  They  are  less 
malignant  than  round-cell  sarcomas,  causing  less  local  disturbance, 
growing  less  rapidly,  and  forming  metastases,  which  are  less  extensive, 
later.  The  spindle-cell  sarcoma  composed  of  large  cells  are,  however, 
almost  as  malignant  as  the  round-cell  varieties. 

Round-cell  sarcomas  are  composed  either  of  small,  round  cells  with 
little  cytoplasm,  or  of  large  epitheliallike  cells,  rich  in  protoplasm  and 
containing  vesicular  nuclei.    If  the  cells  lie  imbedded  in  a  well-developed 


Fig.  343. — Round-Cell  Sarcoma  of  the  Cheek. 


844 


DIFFERENT   VARIETIES  OF   TUMORS 


stroma  (alveolar  sarcoma)  the  tumor  may  resemble  a  carcinoma  very 
closely  histologically.  Koiind-cell  sarcomas  are  characterized  by  a  rapid, 
infiltrating  growth.     They  are  more  frequently  soft  than  hard. 

Usually  a  single  type  of  cell  is  found  only  in  spindle-cell  sarcomas. 
In  other  forms  of  sarcoma,  while  one  type  of  cell  predominates,  a  num- 
ber of  other  types  are  also  found.  Irregular,  atypical,  mitotic  figures 
and  multinuclear  cells,  the  cytoplasm  of  which  is  not  capable  of  divi- 
sion, are  indicative  of  defective  processes  of  growth. 


Fig.  344. 


-Sarcoma  of  the  Skin  of  the  Thigh  in  a  Woman  Sixty  Years  of  Age 
(Small-Cell  Variety). 


(liiiid-cdh,  which  resemble  closely  osteoclasts,  are  found  in  addition 
to  the  round  and  spindle  cells  in  fibrosarcomas,  especially  in  those 
developing  from  bone.  The  giant-cell  sarcomas,  composed  principally 
(if  spindle  cells,  develop  from  the  periosteum  of  the  jaw  (epulis)  or 
i'roiii  the  mai-row  of  long,  hollow  bones  {vide  p.  853).  They  form  a 
rehilivcly  benign  grou})  of  tuiiioi-s. 

Clinical  Course. — The  clinical  course  of  the  sarcomas  arising  from 
lihrou.s  tissue  deitends  upon  the  position  of  the  tumor  and  its  degree  of 


SARCOMAS 


845 


malignancy.     The  diagnosis  is  often  <liffienlt,  espeeially  wlien  the  tumor 
is  just  bcuinninu'  to  develop. 

Sarcomas  of  the  Skin. — Sarcomas  of  the  skin  appear  as  rapidly  grow- 
ing, round,  Avell-defined  nodules  and  masses,  or  as  pedunculated,  fun- 


FiG.  345. — Fibrosarcoma  of  the  Aponeurosis  of  the  Occipito-Frontalis 
(Man  Fifty  Years  of  Age). 

giform,  and  nodular  tumors,  varying  in  consistency.  They  have  a 
bluish-red  color,  as  they  contain  a  large  number  of  vessels,  and,  in  the 
beginning  at  least, 
are  covered  by  epi- 
dermis. Later  the 
skin  becomes  infil- 
trated, and  large, 
deep  ulcers  may 
form,  or  the  surface 
of  the  tumor,  which 
bleeds  easily  and  pro- 
fusely, may  be  cov- 
ered by  crusts.  Sar- 
comas of  the  skin 
often  develop  from 
warts  and  papillo- 
mas. Frequently 
they  are  multiple 
from  the  beginning. 
So  long  as  they  are 
not  large  and  do  not 
extend  deeply,  they 
move  with  the  skin. 
Rapid  growth  indi- 
cates malignancy. 
The  nodular  surface 
of  the  tumor,  or  the 
fissured,  irregular 
ulcer   may   resemble 


Fig.  346.- 


-MlILTIPLE   S.\RCOMAS  OF  THE   SkIX    IN  A  MaN  ForTY 

Years  of  Age  (Small-Cell  Variety). 


846 


DIFFERENT  VARIETIES  OF  TUMORS 


^^^-•».'*- -^      •*       '•         V— ■  -  ^-     •! 


—  ^*% 


^VJ^ 


closely  the   changes    foniid    in   carcinomn.      The    al)sence    of   indurated 

lymphatic  enlargements  enables  one  to  exclude  tlu?  latter.     It  is  often 

difficult  to  distinguish  the  multiple 
sarcomas  from  mycosis  fungoides, 
a  peculiar  disease,  the  etiology  and 
exact  nature  of  "which  are  un- 
known. 

Sarcomas  of  Subcutaneous  Tis- 
sues.— Sarcomas  developing  in  the 
subcutaneous  tissues  appear  as 
round  nodules  with  slightly  un- 
even, tuberculated  surfaces.  In 
the  beginning  they  are  sharply 
defined  against  the  surrounding 
tissues,  but  later  infiltrate  them, 
become  adherent  to  the  skin,  and 
ulcerate  through  it.  They  may  de- 
velop from  fibromas  of  the  nerves. 
The  diagnosis  is  based  principally 
upon  the  rapid  growth.   They  may 

be  easily  differentiated  from  fibromas,  but  with  difficulty  from  rapidly 

developing  subcutaneous  gummas.    A  positive  diagnosis  at  times  can  be 

made  only  by  examining  pieces  of 

tissue,  or  after  ulceration,  when  the 

products  characteristic  of  syphilitic 

lesions  are  wanting. 


S   ♦••  Na^       ^^-1     v^*  ti^ 


Fig.  347. 


-Fibrosarcoma  with  Giant-Cells 
(Epulis). 


Fki.  .348. — Vi:uY  Vasculau  Sarcoma  of  the 
Skin.  The  tu!nf)r  lias  broken  through  the 
skin  which  aurrounds  it  like  a  collar. 


Fig.  349.- 


-Round-Cell  Sarcoma  of  the 

Skin. 


SARCOMAS 


847 


Sarcomas  of  Mucous  Membrane. — Sarcomas  of  the  mucous  membrane 
may  be  composed  of  either  round  or  spindle  cells.  They  usually  grow 
rai)idly.  They  appear  as  nodular  tumors  with  broad  bases,  more  rarely 
as  pedunculated  or  poorly  defined  thickenings,  varying  in  consistency. 
After  destruction  of  the 
nnicous  membrane,  which 
is  apt  to  occur  early, 
craterlike  ulcers  form. 
They  develop  from  the 
submucosa,  more  rarely 
from  the  intermuscular 
and  submucous  connect- 
ive tissues,  and  occur  in 
the  stomach,  intestines, 
and  sometimes  in  the 
tongue  and  trachea.  Sar- 
comas of  the  mucous 
membranes  are  much  less 
frequent  than  are  carci- 
nomas, with  which  they 
have  many  clinical  symp- 
toms in  common. 


Fig.  350. — Section  of  a  Pe- 
dunculated Sarcoma  of 
THE  Skin  (Vascular  Spin- 
dle-Cell Sarcoma)  of  the 
Finger.  The  cutis  does  not 
extend  beyond  the  pedicle. 


Muscle 
Sarcoma 

Fig.  351. — Ulcerated  Round-Cell  Sarcoma  of  the 
Stomach  (Woman  Twenty-three  Years  of  Age. 
Resection  of  Right  Half  of  Stomach,  Recov- 
ery). 


Intermuscular  Sarcomas. — Tnternmscular  sarcomas  are  most  com- 
monly composed  of  large  cells  and  gi-ow  rapidly.  They  may  form  enor- 
mous tumors  entirely  surrounding  the  bones  of  the  part  involved.  The 
diagnosis  is  often  difficult  when  the  tumor  is  seen  in  its  early  stages, 
as  one  has  to  exclude  a  gumma  developing  in  the  muscle.  The  diagnosis 
may  be  difficult  even  in  the  advanced  stages,  as  it  nuiy  be  impossible  to 
determine  whether  the  tumor  has  developed  from  soft  tissues  or  bone.  Be- 
sides the  very  cellular,  soft,  malignant  tumors,  there  are  also  hard,  fibrous, 
intermuscular  tumors  which  grow  slowly  and  are  partially  encapsulated. 


848 


DIFFERENT   VARIETIES  OF  TUMORS 


Both  of  these  forms  are  also  represented  in  sarcomas  developing  from 
fascia  and  the  connective-tissue  sheaths  of  blood  vessels.  The  latter 
especially  give  rise  to  early  symptoms  by  pressure  upon  nerves  and 
blood  vessels. 

Sarcomas  of  the  Periosteum. — The  sarcomas  developing  from  the  peri- 
osteum— in  rare  cases  they  are  multiple   (Nasse) — are  fibrosarcomas  or 


Fig.  352.-^Smal,l,  Round-Cell  Sarcoma  op  the  Hand,  Developing  from  the  Fascia. 
Amputation  was  soon  followed  by  symptoms  indicating  involvement  of  the  lungs.  A 
piece  of  tissue  was  expectorated,  which  resembled  histologically  the  primary  tumor. 
(P'rom  Prof.  Bcvan's  Surgical  Clinic.) 

spindle-cell  sarcomas,  through  which  are  distributed  giant  cells.  They 
are  common,  a[)pearing  as  nochilar,  hard  tumors  upon  the  alveolar 
processes  of  the  jaws.  A  tumor  of  tliis  character  may  be  attached  by 
a  broad  base  or  a  rather  narrow  pedicle.  Such  a  tumor  is  called  an 
epulis.  It  is  often  difficult  to  differentiate  between  these  tumors  and 
(il)fniii;is  Avhich  occur  upon  the  jaws.  These  firm  periosteal  sarcomas 
also  occur  on  other  bones,  especially  on  the  ends  of  long,  hollow  bones. 
Spindle-cell  sarcomas  also  occur  in  the  dura,  forming  a  part  of  the 
tumors  known  as  i'ungns  dui'a-  matris.  The  fibrosarcomas  developing 
fi'oin  hone  mai-i'ow  contain  a  lai-ge  nunil)er  of  giant  cells  and  are  rela- 
tively benign.  Their  position  and  clinical  symptoms  correspond  to 
those  of  myeloid  sarcomas. 


SARCOMAS 


849 


The  nodular,  oncapsulated  tumors  developing  from  the  synovial 
sheaths  of  the  iiexor  tendons  of  the  fingers  have  a  similar  structure,  and 
are,  likewise,  not  very  malignant.  Their  red  or  yellowish-brown  color 
is  due  to  the  deposition  of  blood  pigment  following  ha'morrhages  caused 
by  trauma. 

Sarcomas  of  Nerves. — If  a  sarcoma  develops  from  the  connective  tis- 
sues of  a  nerve,  a  nodular,  fusiform  thickening  or  a  tumor  which  is 
encapsulated  at  first  forms  upon  the  nerves.  These  tumors  grow  more 
rapidly  than  fibromas.  They  press  upon  the  nerves,  giving  rise  to  con- 
siderable pain,  and  may  finally  infiltrate  the  surrounding  soft  tissues. 

Occasionally  a  sarcoma  develops  from  a  sim- 
ple filiroma  which  may  have  existed  for  some 
time. 

Retroperitoneal  Sarcomas.  —  Sarcomas  of 
this  gfou})  develop  in  tlie  posterior  abdom- 
inal wall  and  in  the  mesentery,  forming  large 
growths  with  nodular  surfaces.  They  form 
much  more  extensive  growths  and  develop 
more  rapidly  than  retroperitoneal  fibromas. 

Fibrosarcomas  of  the  different  organs 
(mammary,  thyroid,  and  parotid  glands,  tes- 
ticle, kidney,  uterus,  etc.)  rapidly  destroy  the 
parenchyma  of  the  organ  involved.  The  se- 
rous membranes  (pleura,  peritoneum)  are  but 
rarely  primarily  involved. 


Fig.  353. — Soft,  Small,  Spin- 
dle-Cell Sarcoma  of  the 
Fascia  Lata.    . 


Fig.  354. — Central  Giant-Cell  Sarcoma  of  the  Upper 
Jaw  (Resection  Preparation). 


The  different  forms  of  primary  sarcoma  of  the  lyinpli  nodes,  except- 
ing the  lymphosarcomas,  are  exceptionally  rare. 

Diagnosis. — Usually  one  must  be  content  with  making  a  general  diag- 
nosis  of   sarcoma,   differentiating   it   from  other   forms   of  malignant 


850 


DIFFERENT   VARIETIES  OF  TUMORS 


growths.  Sometimes  the  diagnosis  as  to  the  histological  structure  of  the 
tumor  can  be  based  upon  the  position  of  the  tumor;  for  exami)le,  peri- 
osteal giant-cell  sarcomas  are  common  upon  the  alveolar  processes  of 
the  jaws.  Often  it  is  impossible  to  differentiate  between  a  lympho- 
sarcoma, a  chondrosarcoma,  and  a  myxosarcoma.  The  color  of  a  melano- 
sarcoma,  the  consistency  and  position  of  an  osteosarcoma  enable  one, 
as  a  rule,  to  make  a  positive  diagnosis  as  to  the  character  of  the  tumor. 


Fig.  355. — Giant-Ckll  Sarcoma  of  the  Mammary  Gland  (mostly  Largp:  Cells). 


It  is  often  exceedingly  (liriiciill  to  make  a  diagnosis  between  a  sarccmia 
and  a  deep  inlUunmatory  mass,  especially  a  gumma.  In  these  cases  an 
exploratory  incision  is  a  much  more  rapid  diagnostic  method  than  anti- 
syphilitic  treatment. 

Treatment. — The  treatment  of  a  sarcoma  consists  of  as  early  and 
complete  removal  as  possible,  if  there  are  no  diMiionstrable  metastatic 
growths.  If  the  tumor  is  so  situated  that  an  amputation  is  possible,  it 
should  be  perfoi'iiied  if  there  arc  no  ccmtra-indications. 


SARCOMAS 


851 


CHONDRO-    AND    OSTEOSARCOMAS 


Chondro-  and  osteosarcomas  develop  from  the  skeleton;  more  rarely 
from  the  soft  tissues. 

Chondrosarcomas  are  closely  related  pjenetically  to  chondromas,  from 
which  they  may  develop,  and  occur  in  the  same  regions.  They  are  char- 
acterized, like  the  chondromas,  by  the  formation  of  a  hyaline  ground 
substance.  They  differ  from  the  chondroma  in  that  they  are  more  cellu- 
lar, being  composed  of  groups  or  columns  of  round,  fusiform,  or  poly- 
morphous cells,  surrounded  by  small  or  large  islands  of  cartilaginous  sub- 
tance.  Within  this  ground  substance  lie  isolated  groups  of  cartilage 
cells,  usually  without  a  capsule. 

Appearance  of  Cut  Surface. — The  cut  surface  of  a  chondrosarcoma 
does  not  have  the  homogeneous  appearance  of  the  cut  surface  of  the  chon- 
droma. The  cartilaginous  parts  appear  as  opal,  bluish  areas  in  the  soft, 
reddish,  sarcomatous  tissue.  Calcification  of  the  cartilage  is  indicated  by 
the  development  of  white  areas  in  the  tumor,  ossification  by  its  hardness 
(chondro-osteosarcomas).  Softening  with  subsequent  liquefaction  may 
lead  to  the  formation  of  large  cystic  cavities.  Chondrosarcomas  grow 
rapidly,  often  attaining  enormous  size,  infiltrating  the  soft  tissues,  and 
destroying  bone.  Not  infrequently  they  form  metastases,  as  the  prolifera- 
tion of  the  cells  is  so  rapid 
that  there  is  scarcely  time  for 
the  formation  of  a  capsule. 

Osteosarcomas.  —  Osteosar- 
comas, or  ossifying  sarcomas, 
are  much  more  common  than 
chondrosarcomas.  Strictly 
speaking,  one  means  by  an 
osteosarcoma  a  tumor  which 
contains  bone  or  its  ante- 
cedents, and  not  a  fibrosar- 
coma developing  from  bone. 
It  is  not  always  possible  to 
make  a  sharp  distinction,  as  a 
fibrosarcoma  developing  from 
the  periosteum  may  contain 
bone  formed  by  the  reactive 
growth  of  the  latter. 

Osteosarcomas  develop 
most  frequently  in  the  ends  of  long  hollow  bones,  in  the  bones  of  the 
pelvis,  the  scapula,  the  clavicle,  the  sternum,  the  bones  of  the  skull,  the 
short,  hollow  bones,  the  vertebrae,  the  os  calcis,  and  the  patella.     They 


Fi< 


:.      :;.i(i. I    ll;|i>>M     W         '   >'    I   I   '  i-  \r(('MM  A       CM'      THE 

Ulna.  Sarcoiuatous  li.ssuo  with  giaiit-cells  and 
osteoblasts  may  be  seen  between  newly  formed 
calcified  (a)  and  osteoid  (b)  lamelloe. 


852 


DIFFERENT   VARIETIES  OF  TUMORS 


develop  most  frequently  during  the  period  of  growth  and  are  divided 
into  periosteal  (peripheral)  and  myelogenous  (central)  tumors. 

Periosteal  sarcomas  (Fig.  356)  are  composed  mostly  of  spindle  cells,  but 
also  contain  i-ound-  and  giant-cells.  The  cells  lie  in  a  stroma,  which  resem- 
bles bone,  and  sometimes  is  arranged  in  regular  lamellae,  and  at  other  times 
has  no  definite  arrangement  whatever.  If  the  tumor  contains  only  deli- 
cate, non-calcified,  osteoid  lamella*,  it  is  spoken  of  as  an  osteoid  sarcoma. 
These  tumors  are  closely  related  to  those  less  malignant  tumors  which  are 
composed  of  broad,  non-calcified  lamellfe  of  a  cartilaginous  ground  sub- 
stance, between  which  are  found  irregular  cells,  which  have  been  called 
osteoid  chondromas  by  Virchow.    The  formation  of  bone  is  rarely  evenly 

distributed  throughout  the  whole  of 
the  tumor.  It  is  much  more  advanced 
in  the  older,  central  parts  of  the  tu- 


Fio.  357. — Periosteal,  Osteosaijcoma 
OF  THE  Lower  End  op  the  Femur 
WITH  A  Radiating  Arrangement 

OF   THE   ThAHECUL.K   OF   BoNE. 


Fig.  35S. — Cystic  O  teosarcoma  of  the 

Sternum. 


mor  than  in  the  cellular,  and  therefore 
softer,  peripheral  parts.  Areas  com- 
posed of  tissue  resembling  bone  alter- 
nate with  those  composed  of  osteoid 
or  chondroid  tissue.  The  lamella?,  which  frequently  contain  and  are 
surrounded  by  osteoblasts,  either  form  a  spongy  framework  in  which 
the  sarcoma  cells  and  the  vessels  supplying  the  marrow  lie,  or  are 
arranged  so  that  after  maceration  (Fig.  857)  they  appear  as  needles 
and  pi'ojeetious  radiating  in  all  directions  or  irregularly  grouped. 

Periosteal  sarcomas  appear  in  the  beginning  as  circumscribed  nod- 
ules, varyuig  in  consistency  and  covered  by  a  layer  of  })ei'iost(Mnii. 
They  are  most  common  in  long,  hollow  bones,  beginning  as  a  rule  about 


SARCOMAS 


853 


the  metaphysis.  During  later  growth  such  a  tumor  may  involve  the 
entire  bone,  which  then  becomes  transformed  into  a  shapeless,  nodular 
mass  resembling  a  club.  If  the  tumor  grows  slowly,  forming  considerable 
bone,  only  the  superficial  part  of  the  cortex  is  destroyed  and  the  base 

of  the  tumor  is  surrounded  by  osteophytes. 
If  the  tumor  grows  rapidly  and  perforates 
its  capsule,  it  invades  muscles,  tendons,  and 


Fig.  359. — Myelogenous  Sarco- 
ma   OF     THE     LOAVER     End    OF 

THE  Femur,  which  has  Ex- 
tended Along  the  Surface 
OF  the  Bone  After  Rupture 

THROUGH  THE   EPIPHYSIS. 


Fig.  360. — Osteoid  Sarcoma  of  the  Patella  (Sag- 
ittal Section  THROUcni  the  Knee  Joint). 


ligaments,  and  passes  along  the  Haversian  canals  to  the  medullary  cav- 
ity, destroying  the  cortex.  The  tumor  can  be  differentiated  from  the 
bone  marrow  by  its  lighter  color.  In  advanced  cases,  therefore,  it  is 
often  difficult  to  determine  whether  the  tumor  originated  in  the  peri- 
osteum or  bone  marrow.  The  articular  cartilage  resists  for  the  longest 
time  the  invasion  of  the  tumor,  but  the  joint  capsule  may  be  early 
involved  at  its  line  of  attachment  to  the  bone,  and  the  tumor  may  ex- 
tend to  the  joint  cavity  in  this  way. 

The  clinical  picture  of  the  periosteal  sarcoma  resembles  very  closely 
that  of  the  myelogenous.  The  periosteal  has  no  bony  shell  surround- 
ing it,  which  is  present  in  the  beginning  of  the  myelogenous  forms. 

Myeloid  Sarcomas. — The  myelogenous  osteosarcomas,  or  myeloid  sar- 
comas, occur  most  frequently  in  the  spongy  ends  of  long,  hollow  bones 


854 


DIFFERENT   VARIETIES   OF   TUMORS 


(especially  in  young  people),  being  situated  in  the  metaphysis  close  to 
the  epiphyseal  cartilage  more  frequently  than  in  the  epiphysis.     They 

may,  however,  develop  in  any  other  of  the 
bones.  The  mandible,  carpal,  and  tarsal  bones, 
the  bones  of  the  skull,  the  vertebrae,  and  pelvic 
boiies  are  most  frequently  involved  after  the 
long  bones.  Multiple  myeloid  sarcomas  have 
been  observed,  especially  in  association  with 
osteitis  deformans  (p.  749). 

Histology. — They  are  composed  of  round 
and  spindle  cells  or  large  cells  of  different 
shapes,  and  contain  giant  cells  more  frequently 
than  the  periosteal  forms.  Generally  the  for- 
mation of  bone  is  less  marked  than  the  cellular 
proliferation.  These  tumors  are  exceedingly 
vascular  and  may  pulsate.  They  are  often 
spoken  of  as  ho7ie  aneurysms.  Thrills  may  be 
elicited  upon  palpation  and  bruits  upon  aus- 
cultation. Haemorrhages  within  the  tumor 
tissue  are  relatively  common,  and  pigment  is 
deposited  in  tile  tissues  which  assume  a  yellow- 
ish or  reddish  brown  color.  Softening  with 
subsequent  liquefaction  leads  to  the  formation 
of  cysts,  the  walls  of  which  contain  trabeculae 
of  bone. 

Mode  of  Growth. — 
Generally  these  tumors 
have  an  expansive 
growth  for  some  time, 
and  are  therefore  rela- 
tively benign,  being  the 
lenst  malignant  of  all 
sarcomas.  This  is  especially  true  of  the  tumors 
composed  of  spindle  cells  with  a  fibrous  or  osteal 
ground  substance,  and  containing  large  numbers 
of  giant  cells.  As  the  tumor  grows  the  bone  be- 
comes expanded,  but  not,  as  in  inflammatory 
processes,  as  the  result  of  a  thickening  of  the 
cortex.  The  cortex  gradually  undergoes  a  pres- 
sure atrophy  from  within  as  the  tumor  enlarges, 
and  is  not  replaced  by  new  bono  foi-med  from 
the  periostemn.  The  bone  suri-ouiiding  a  central  tumor  is  gradually 
destroyed,  and  spontaneous  or  pjitliological  fractures  may  occur.    Some- 


FlG, 


361. —  Osteosarcoma 
OF  THE  Fibula. 


Fig.  362. — MYf:LOGENous 
Giant-Cell  Sarcoma 
OF  THE  Lower  End  of 
THE  Radius  (Woman 
Thirty  -  five  Years 
OF  Age.  Resection 
Preparation.  No 
Recurrence  After 
Four  Years). 


SARCOMAS 


855 


times,  especially  in  sarcomas  of  the  jaw,  the  thin,  yielding  shell  of 
bone  imparts  a  "  parchmentlike  crackle  "  (Dnpnytren)  to  the  pal- 
j)ating  finger.  If  the  periosteal  bone  formation  is  not  as  rapid  as 
the  bone  absorption,  the 
bony  capsule  surround- 
ing the  tumor  is  sooner 
or  later  ruptured,  and 
the  tumor  then  extends 
to  the  soft  tissues  and 
invades  the  joint  and 
surrounding  bone.  In- 
filtrating growth  then 
predominates,  resulting 
in  the  rapid  formation 
of  metastases. 

Malignant  Transfor- 
mation.— The  transition 
from  a  relatively  benign 
to  a  malignant  stage 
does  not  progress  with 
the  same  rapidity  in  all 
cases.  The  soft,  cellu- 
lar forms  (the  so-called 
medullary  forms)  rup- 
ture through  their  cap- 
sule and  assume  an  in- 
filtrating growth  much 
earlier  than  the  firm 
forms  (containing  large 
numbers  of  giant-cells), 
which,  even  after  exten- 
sion to  the  loft  tissues, 
may  preserve  for  a  long 
time  their  tendency  to 
limitation  and  expansive 
growth. 

Symptoms. — Usually 
the  first  symptoms  are 
pain  and  rapidly  devel- 
oping enlargement  of 
the   bone   involved.      In 

myeloid  sarcomas   of   the   bones   of  the   extremities,    spontaneous   frac- 
tures and  a  serous  exudate  into  the  neighboring  joint  may  develop  early 


Fig.  363. — Central  Osteosarcoma  of  the  Femur  with 
Rupture  into  the  Soft  Tissues  and  Knee  Joint. 


856 


DIFFERENT   VARIETIES  OF  TUMORS 


If  the  pain  and  enlargement  of  the  hone  have  not  been  marked,  it  is 
often  difficult  to  interpret  correctly  the  clinical  significance  of  the  frac- 
ture or  of  the  accumulation 
of  fluid  in  the  joint. 

The     more     rapid     the 
growth,  the  earlier  the  func- 
tional  disturbances,  result- 
ing from  the  displacement 
and  infiltration  of  the  mus- 
cles  and   nerves  and   from 
pressure     upon     the     large 
veins,  develop.     The  symp- 
toms depend  upon  the  po- 
sition of  the  tumor 
(for  example,  a  tu- 
mor  growing   into 
the  cranial  cavity 
from     the     sur- 
rounding    bones 
produces    symp- 
toms   of    cerebral 
compression ;  a  tu- 
mor developing 
from  the  bones  of 
the  thorax,  symp- 
toms of  lung  com- 
pression).     Deep 
ulcers,  which  bleed  profusely  and  easily  become  infected,  follow  infiltra- 
tion of  the  skin. 

Diagnosis. — The  diagnosis  in  advanced  cases  is  based  upon  the  pres- 
ence of  a  large,  rapidly  growing  tumor  which  is  firmly  attached  to  the 
bone  involved  by  a  broad  base.  The  boundaries  of  the  tumor  cannot 
be  sharply  defined,  as  in  the  advanced  cases  the  tumor  has  already  con- 
tracted adhesions  with  the  surrounding  muscles.  Sometimes  it  can  be 
deinonstrated  that  the  function  of  the  muscle  is  interfered  with  or  lost, 
indicating  that  it  has  been  infiltrated  by  tumor  tissue.  In  the  large 
and  rapidly  growing  tumors,  symptoms  of  metastatic  lung  foci,  accom- 
panied by  those  of  a  pleuritic  effusion,  are  frequently  present. 

It  is  often  impossible  to  determine  by  the  position  and  consistency 
of  llic  tumor  whether  it  developed  primarily  from  the  periosteum  or 
medulla,  or  even  from  the  soft  tissues,  whether  it  is  an  osteo-,  chondro-, 
or  filjrosarcoma.  This,  however,  is  of  little  practical  importance.  Mye- 
logenous are  more  common  than  periosteal  forms,  and  often  cause  spon- 


FiG.  364. — Osteosarcoma  of  iiii.  L  iikr  End  of  the  Humerus 
IN  A  Patient  Nineteen  Years  of  Age. 


SARCOMAS 


857 


taneous  fractures.  The  early  diagnosis  is  difficult.  The  symmetrical 
enlaro-ement  of  the  bone,  accompanied  by  an  acute  hydrops  of  the 
neighboring-  joint,  may  suggest  some  chronic  infiannnatory  process,  such 
as  tuberculosis  or  syphilis.  Sarcomas  frequently  develop  in  parts  of 
the  bone  where  chronic  inflammatory  processes  (such  as  tuberculosis  and 
syphilis)  are  common,  and  are  often  accompanied  by  some  fever.  The 
small  periosteal  sarcomas  resemble  quite  closely  fibromas,  chondromas, 
and  osteomas,  being-  nodular  and  hard.  A  spontaneous  fracture  favors 
the  diagnosis  of  sarcoma,  but  even  when  a  sioontaneous  fracture  is 
present  a  positive  diagnosis  cannot  always  be  made.  A  sarcoma  cap- 
not  be  excluded  even 
when  the  lesions  are 
multiple,  but  the  prob- 
abilities are  that  when 
lesions  are  primarily 
multiple  the  tumors  are 
not  malignant. 

In  all  eases  care- 
ful clinical  observations 
are  necessary,  but  they 
should  not  be  extended 
over  too  long  a  period. 
If  the  skin  over  a  rap- 
idly growing"  tumor  be- 
comes red,  the  diagnosis 
must  be  made  between 
a  suppurative  osteomye- 
litis and  a  gumma,  for  a 
tuberculous  lesion,  even 
after  rupture  into  the 
soft  tissues,  does  not  in- 
crease rapidly  in  size, 
and  a  sarcoma,  although 
containing  a  large  num- 
ber of  vessels  and  some- 
times caiLsing  fever,  does 
not  produce  an  inflam- 
matory redness  of  the 
skin  covering  it.  If,  dur- 
ing the  period  of  obser- 
vation, potassium  iodid 
has  been  administered  without  results,  chronic  suppurative  osteomye- 
litis is  the  only  diagnosis  that  can  be  made.  If,  on  the  other  hand, 
55 


Fig.  365.  —  Preparation  from 
THE  Same  Case  Seen  from 
Behind.  (Removal  of  the 
shoulder  girdle.) 


858 


DIFFERENT  VARIETIES  OF  TUMORS 


there  is  no  iiiflannnatory  redness  of  tlie  skin,  a  diagnosis  of  tumor  may- 
be made,  and  it  may  be  reyarded  as  a  myelogenous  form  if  a  bony  cap- 
sule can  be  demonstrated,  either  by  palpation  or  the  X-ray.  Rapid 
growth  spealcs  for  a  sarcoma  and  against  benign  tumors  (fibroma,  chon- 
droma,  echinococcus  cysts   of  bone).     It  should,   however,   be   clearly 

understood  that  many  sar- 
comas have  a  relatively  slow 
growth.  If  there  is  any  sus- 
picion that  the  lesion  is  of  a 
sarcomatous  nature,  clinical 
observations  should  not  be 
prolonged  for  more  than  one 
or  two  weeks.  [In  these 
cases  an  exploratory  incision 
should  be  made  early,  and  if 
the  macroscopic  appearances 
are  characteristic  enough  to 
justify  a  diagnosis  of  sar- 
coma, the  lesion  should  be 
removed.  If  the  lesion  is 
not  sufficiently  characteris- 
tic, tissue  should  be  removed 
and  examined  microscopical- 
ly, and  then  if  the  lesion  is 
malignant,  operative  meas- 
ures, unless  there  are  contra- 
indications, should  be  advised 
at  once.] 

X-ray  pictures  frequently 
aid  in  making  a  diagnosis. 
Exostoses  may  be  easily  rec- 
ognized, as  they  are  conical 
or  pedunculated,  and  their 
sharp  outlines  become  con- 
tinuous with  those  of  the 
bone.  In  pictures  of  peri- 
osteal sarcomas,  on  the  other 
hand,  one  sees  irregular, 
cloudy  shadows,  the  density 
of  wliicli  depends  upon  llie  amount  of  l)one  the  tumor  contains.  The 
boundaries  of  the  tumor  gradually  become  continuous  with  the  outlines 
of  tlie  hone,  which  are  indistinct  at  the  points  where  the  growth  has 
reached  the  periosteum.     In  myelogenous  sarcomas  a  faint  shadow,  sur- 


FiG.  366. — Soi-r,  Si'indle-Celi.  Sarcoma  of  the 
Upper  Epiphysis  of  the  Humerus  Removed 
FROM  A  Girl  Fourteen  Years  Old. 


SARCOMAS  859 

rounded  by  a  thin,  expanded  cortical  layer  of  bone,  may  be  seen  when 
the  bone  surrounding;  the  tumor  has  undergone  pressure  atrophy.  The 
bright  shadows  merely  indicate  destruction  of  bone,  and  may  be  found 
in  abscesses  and  cysts  as  well  as  in  tumors  (sarcoma,  chondroma). 

A  delicate  bony  capsule,  however,  speaks  against  inflammatory  foci 
of  all  kinds,  even  against  tul)erculosis,  at  least  as  it  occurs  in  long, 
hollow  bones,  and  the  symmetrical  shadows  with  indistinct  boundaries 
against  chondromas  and  cysts.  Similar  findings  enable  one  to  make  a 
positive  diagnosis  in  spontaneous  fractures.  If  a  central  gumma  is 
considered,  the  differential  diagnosis  can  be  easily  made,  as  the  gumma 
is  always  associated  with  irregular  hyperostoses  developing  from  the 
cortex. 

The  diagnosis  is  most  difficult  when  a  rapidly  growing,  soft,  peri- 
osteal or  myelogenous  sarcoma  invades  an  adjacent  joint.  As  the  tumor 
invades  the  joint  capsule  and  para-articular  tissues,  a  doughy  swelling 
develops  and  the  joint  becomes  fusiform  in  shape,  suggesting  a  tuber- 
culous or  hgemophiliac  lesion,  the  latter  especially,  as  aspiration  reveals 
blood.  The  X-ray  findings  are,  as  a  rule,  not  definite  enough  to  enable 
one  to  make  a  positive  diagnosis.  If  a  careful  examination  is  made,  a 
tumor  attached  to  the  bone  near  the  joint  may  be  palpated.  Soon,  how- 
ever, the  tumor  extends  beyond  the  joint,  and  the  extremity  enlarges 
as  the  result  of  circulatory  disturbances.  The  enlargement  is  in  marked 
contrast  to  the  atrophy  associated  with  tuberculosis  of  joints  (Fig.  363). 

In  children  the  soft,  myelogenous  tumors,  developing  in  the  metaph- 
ysis,  often  cause  a  separation  of  the  epiphysis.  In  these  cases  a  diagnosis 
of  suppurative  osteomyelitis  may  be  made,  especially  if  the  soft  tumor 
masses  fluctuate  and  there  is  fever. 

It  may  be  very  difficult  at  times  to  differentiate  between  a  tumor 
of  this  character  and  an  aneurysm  if  the  tumor  develops  adjacent  to 
a  large  blood  vessel  (e.  g.,  in  the  axillary  fossa  or  popliteal  space),  for 
a  telangiectatic  sarcoma  which  pulsates  may  form. 

Illustrative  Cases  to  Demonstrate  Difficulties  in  Diagnosis. — A  few 
examples  may  be  cited  to  illustrate  how  difficult  it  is  at  times  to  make  a 
correct  diagnosis. 

A  boy  ten  years  of  age  fell  ill  Avith  a  swelling  of  the  entire  left  arm. 
When  first  seen  the  arm  was  oedematous  and  the  subcutaneous  veins 
dilated.  The  cause  of  the  venous  stasis  was  a  thickening  of  the  left 
clavicle.  This  thickening,  which  gradually  fused  with  the  deeper  struc- 
tures, was  covered  by  normal  skin.  The  diagnosis  rested  between  a 
chronic  suppurative  osteomyelitis  and  a  sarcoma  of  tlie  clavicle.  After 
two  weeks'  observation  the  skin  over  the  thickened  area  became  slightly 
reddened  and  made  the  diagnosis  of  osteomyelitis  positive.  A  focus 
of  granulation  tissue  which  communicated  through  a  cloaca  Avith  the 


860  DIFFERENT   VARIETIES   OF   TUMORS 

interior  of  the  bone  was  situated  beneath  the  reddened  skin.  The  path- 
ology corresponded  to  that  of  the  sclerotizing  form  of  suppurative  osteo- 
myelitis. Permanent  healing  occurred  after  the  newly  formed  bone  was 
chiseled  away  and  the  granulation  tissue  removed. 

A  boy  fifteen  years  of  age  fell  ill  with  a  painful  swelling  of  the 
upper  articular  end  of  the  left  tibia.  For  two  weeks  the  swelling  had 
rapidly  increased  in  size,  especially  anteriorly  just  below  the  tuberosity, 
where  it  was  firmly  attached  to  the  skin.  The  temperature  was  about 
98.8°  F.  X-ray  pictures  were  negative.  The  diagnosis  rested  between 
a  periosteal  sarcoma  and  a  superficial  suppurating  focus.  The  ex- 
ploratory incision  revealed  a  soft  periosteal  sarcoma. 

Three  weeks  before  examination  a  slightly  painful,  poorly  defined 
swelling  developed  in  the  middle  of  the  right  leg  over  the  fibula,  in  a 
man  forty-five  years  of  age.  The  skin  was  slightly  adherent  to  the 
hard  swelling,  the  contour  of  which  became  continuous  with  the  fibula. 
Was  the  lesion  a  sarcoma,  a  suppurative  osteomyelitis,  or  a  gumma  of  the 
fibula?  The  X-ray  pictures  revealed  an  irregularly  thickened  fibula 
surrounded  by  a  faint  shadow  cast  by  the  mass.  The  thickening  was 
not  distinct  enough  to  warrant  a  diagnosis  of  a  gumma.  After  a  week 
the  skin  over  the  swelling  became  reddened.  A  sarcoma  could  be  ex- 
cluded with  certainty  and  a  tentative  diagnosis  of  a  chronic  suppura- 
tive osteomyelitis  could  be  made.  Just  as  an  operation  was  about  to 
be  performed  a  round,  white  scar  the  size  of  a  nickel,  such  as  remains 
after  the  healing  of  a  syphilitic  ulcer,  was  found  upon  the  other  leg. 
The  swelling  disappeared  completely  under  antisyphilitic  treatment. 

A  woman  thirty-five  years  of  age  sufi'ered  for  a  week  with  a  swelling 
of  the  right  wrist  joint,  which  was  supposed  to  be  the  result  of  a  sprain. 
The  joint  was  immobilized  for  two  weeks,  and  when  the  dressings  were 
removed  the  exudate  had  disappeared.  Some  slight  thickening  of  the 
lower  end  of  the  radius  which  suggested  some  infiammatory  lesion,  such 
as  tuberculosis  or  suppurative  osteomyelitis,  or  a  sarcoma  could  then  be 
palpated.  The  X-ray  pictures  revealed  a  bright  shadow  surrounded 
by  a  thin  layer  of  bone;  therefore  a  suppurating  focus  could  be  ex- 
cluded. The  complete  destruction  of  the  spongy  bone  of  the  metaphyais 
and  of  the  epiphysis  spoke  against  tuberculosis. 

The  operation  revealed  a  myelogenous  giant-cell  sarcoma  about  to 
rupture  into  the  joint.  The  resected  portion  of  the  bone  is  reproduced 
in  Fig.  362.  The  patient  is  well,  and  no  recurrences  have  developed 
four  years  after  the  operation. 

An  emaciated  man,  twenty  years  of  age,  developed  a  painful  swell- 
ing of  the  right  knee  soon  after  a  fall.  The  joint  was  greatly  swollen, 
and  the  normal  outlines  of  the  joint  were  lost  as  tlie  capsvde  was  filled 
with  an  exudate.    The  swelling  was  of  a  doughy  consistency  ;  fluctuation 


SARCOMAS  861 

and  patellar  Ijalottcnicnt  could  he  elicited  only  when  considerable  pres- 
sure was  made.  Tiie  entire  clinical  picture  resembled  closely  that  of 
tuberculosis.  Aspiration  revealed  dark  blood.  It  was  possible,  there- 
fore, that  the  lesion  might  have  been  due  to  haemophilia,  and  the  patient 
gave  a  history  suggestive  of  this  disease.  The  joint  was  therefore  im- 
mobilized for  two  weeks.  After  this  time  a  soft  swelling  attached  to 
the  bone  could  be  demonstrated,  which  extended  upward  above  the 
condyle  of  the  femur.     X-ray  pictures  at  this  time  were  negative. 

A  diagnosis  of  sarcoma  of  the  femur  with  rupture  into  the  joint  was 
made,  which  was  verified  by  operation  (amputation  of  the  thigh).  A 
soft  myelogenous  sarcoma  which  was  very  vascular  and  cystic  had  rup- 
tured through  the  cortex  at  the  point  of  attachment  of  the  capsular  liga- 
ment, and  had  first  extended  into  the  joint  and  later  upward  along  the 
bone. 

For  other  examples  see  chapter  dealing  with  diagnosis  of  suppura- 
tive, tuberculous,  and  syphilitic  lesions  of  bone. 

Significance  of  Glandular  Enlargement. — The  glandular  enlargements 
which  occur  in  many  cases  of  sarcoma  of  bone  (Nasse)  are  not  of  much 
value  in  making  an  early  diagnosis.  The  enlargements  are  frequently 
caused  by  the  absorption  of  decomposition  products  from  the  tumor, 
and  in  the  beginning  they  cannot  be  differentiated  from  inflammatory 
hyperplasias. 

Prognosis. — The  prognosis  of  sarcomas  developing  from  bone  is  usu- 
ally bad.  Even  the  more  benign  forms  gradually  lead  to  a  destruction 
of  bone  and  the  formation  of  metastases. 

Indications  for  Treatment. — There  is  no  question  that  sarcomas  de- 
veloping from  bone  or  cartilage  should  be  completely  removed  when 
there  are  no  metastatic  growths,  unless  they  are  so  large  or  are  so 
situated  that  removal  is  impossible.  The  extent  of  the  operation  that  is 
necessary  varies,  as  all  of  these  tumors  are  not  of  the  same  degree  of 
malignancy.  The  indication  as  to  the  extent  of  the  operation  that  should 
be  performed  is  dependent  to  a  certain  degree  upon  the  character  of 
the  cells  composing  the  tumor,  as  it  is  well  known  that  giant-cell  sar- 
comas represent  the  most  benign,  small,  round-cell  sarcomas  the  most 
malignant  form  of  this  class  of  tumors.  The  character  and  rapidity  of 
the  growth  also  determine,  to  some  extent,  the  character  of  the  opera- 
tion. Well  encapsulated  tumors  with  an  expansive  growth — especially 
giant-cell  sarcomas,  which  may  be  recognized  by  their  brownish-red 
color — may  be  removed  by  blunt  dissection  with  a  periosteal  elevator  or 
shelled  out  with  a  sharp  spoon.  Experience  has  shown  that  even  after 
such  a  conservative  procedure  as  this  the  dangers  of  recurrence  are  not 
great.  Usually,  even  in  the  treatment  of  encapsulated  tumors,  it  is  to 
be  recommended  that  a  part  of  the  surrounding  bone,  the  parent  tissue 


862  DIFFERENT  VARIETIES  OP  TUMORS 

of  the  tumor,  be  removed.  Tlie  pai-t  of  the  bone  involved  should  ])e  com- 
pletely removed  with  a  chisel,  bone-cutting  forceps,  or  saw,  if  the  bony- 
capsule  is  thin.  If  the  tumor  is  situated  upon  one  side  of  the  bone, 
or  is  surrounded  by  a  thick  layer  of  the  same,  it  may  be  completely 
removed  and  the  continuity  of  the  bone  still  be  preserved  by  an  osteal 
bridge. 

Extensive  resections  of  bone  have  given  good  results  even  in  the 
treatment  of  central  and  periosteal  sarcomas  which  have  ruptured 
through  their  capsules.  Of  course  the  results  following  resection  have 
only  been  good  when  the  operation  was  performed  before  the  tumor 
involved  the  soft  tissues  (von  Bergmann,  von  Bramann,  von  Mikulicz, 
Nasse,  and  others).  In  the  other  forms  of  sarcoma  nodules  develop 
very  early  in  the  part  of  the  bone  adjacent  to  the  primary  focus  after 
resection  (Konig).  The  resected  end  of  the  bones  may  be  approximated 
and  held  in  apposition  by  silver  wire  or  strong  catgut  sutures  or  a 
piece  of  dead  bone  may  be  placed  between  them.  Of  course  the  frag- 
ments should  be  immobilized  until  union  is  complete.  If  the  tumor 
has  already  infiltrated  the  soft  tissues,  or  if  it  is  a  soft,  rapidly  growing 
one,  an  amputation  should  be  performed  if  it  is  situated  upon  an  ex- 
tremity; if  the  tumor  occurs  upon  the  trunk,  neck,  or  head,  it  and  the 
tissues  adjacent  should  be  removed — for  example,  if  the  sarcoma  is  in 
the  orbit,  the  eye  should  be  removed.  In  the  treatment  of  large  tumors 
of  the  thorax  it  is  often  necessary  to  open  the  abdominal  and  thoracic 
cavities. 

Nasse  has  determined,  in  examining  tissues  from  a  number  of  osteo- 
sarcomas, that  the  cells  frequently  extend  early  in  the  clinical  course 
of  these  growths  along  the  blood  vessels  of  the  muscles.  This  imposes 
upon  the  surgeon  not  only  the  duty  of  operating  as  soon  as  possible, 
but  also  of  removing  all  those  muscles  attached  to  the  bone  involved, 
even  to  their  points  of  origin — that  is,  above  the  adjacent  joint.  There- 
fore this  rule  has  been  formulated,  that  in  sarcomas  of  the  forearm 
or  leg  a  high  amputation  of  the  arm  and  thigh  respectively  should  be 
performed;  in  sarcoma  of  the  humerus  the  entire  upper  extremity  in- 
cluding the  shoulder  girdle  should  be  removed;  in  sarcoma  of  the  femur 
a  disarticulation  at  the  hip  should  be  performed  with  the  removal  of 
all  the  muscles  passing  from  the  pelvis  to  the  femur. 

[After  operations  for  sarcoT)ia  the  mixed  toxins  of  i)rodigiosus  and 
erysipelas  (Coley)  should  be  used  as  an  insurance  against  recurrence.] 

The  prognosis  of  sarcomas  developing  from  bone  is  bad.  Reinhardt 
cstiinates  that  permanent  recoveries  occur  in  only  18  per  cent  of  the 
cases.  These  unfavorable  results  arc  iiiucli  iiioi-e  often  due  to  metas- 
tases, especially  in  the  lungs,  than  to  local  recurrences.  The  metastases 
«»rit'ii  develop  so  rapidly  nfter  the  ()i)eration  that  it  is  probable  the  cells 


SARCOMAS  863 

had  already  been  deposited,  l)nt  that  the  foci  were  not  large  enough 
to  give  rise  to  symptoms  or  demonstrable  physical  findings. 

Concerning  the  treatment  oi'  inoperable  sarcomas  vide  p.  775. 

Chondro-  and  osteosarcomas  developing  from  the  soft  tissues  are  of 
much  less  surgical  importance  than  those  arising  from  bone.  They  occa- 
sionally develop  in  fascia  (Ilannner),  from  the  intermuscular  connect- 
ive tissue,  in  the  mammary  gland,  the  spermatic  cord  (Ribbert),  and 
more  frequently  in  mixed  tumors. 

Literature. — v.  Franquc.  Ueber  Sarcoma  uteri.  Zeitschr.  f.  Geburtsh.  u.  Gyniik., 
Bd.  40,  1899,  p.  183. — Friedrich.  Die  Osteoplastik  bei  ausgedehnten  operativcn 
Diaphj'sendefekten  der  langen  Rohrenknochen  jugeudlicher  Individuen  nach  Entfernung 
bosartiger  Knochengcschwulste.  Zentralbl.  f.  Cliir.,  1904,  No.  27,  p.  26. — Hammer. 
Ueber  ein  malignes  fasziales  Riesenzellensarkom  mit  Kuochenbildung.  Btntr.  z.  klin. 
Chir.,  Bd.  31,  1901,  p.  727. — Jenckel.  Beitrag  zur  Kenntni.s  der  Knochensarkome  des 
Oberscheukels.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  64,  1902,  p.  66. — Johannessen.  Sar- 
coma pelvis  bei  einem  11  Monate  alten  Madchen.  Jahresber.  f .  Kinderheilk. ,  1897. — ■ 
Kaposi.  Ueber  einen  Fall  von  sogen.  Sarcomatosis  cutis.  Beitr.  z.  klin.  Chir.,  Bd. 
24,  1893,  p.  526. — W.  Kramer.  Beitrag  zur  chir.  Behandlimg  der  bosartigen  Sarkome 
der  langen  Rohrenknocken.  Arch.  f.  klin.  Chir.,  Bd.  66,  1902,  p.  792. — Kiimmell. 
Tumoren  (Sarkome)  der  Wirbelsaule.  Deutsche  med.  Wochenschr.,  1902,  Vereinsbeil, 
p.  131. — Martens.  Zur  Kenntnis  der  bosartigen  Oberkiefergeschwi'ilste.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  44,  1897,  p.  483. — v.  Mikulicz.  Ueber  ausgedehnte  Resektionen 
der  lamen  Rohrenknochen  wegen  maligner  Geschwiilste.  Chir.  Kongr.-Verhandl. 
1895,  II,  p.  351.  Disk.  Konig,  I,  p.  104.—/?.  F.  Midler.  Zur  Kenntnis  der  Finger- 
geschwiilste.  Arch.  f.  klin.  Chir.,  Bd.  63,  1901,  p.  348. — Nasse.  Ueber  einen  Fall  von 
multiplem,  primarem  Sarkom  des  Periostes.  Virch.  Arch.,  Bd.  94,  1883,  p.  46;  — 
Die  Sarkome  der  langen  Extremitatenknochen.  Arch.  f.  klin.  Chir.,  Bd.  39,  1889,  p. 
886; — Die  Exstirpation  der  Schulter  und  ihre  Bedeutung  fiir  die  Behandlung  der  Sar- 
kome des  Humerus,  v.  Volkmanns  Samml.  klin.  Vortrage,  No.  86,  1893. — Nenfeld. 
Kongenitales  Osteosarkom  des  Schadels.  Beitr.  z.  klin.  Chir.,  Bd.  13,  1895,  p.  730. — 
Rchn.  Multiple  Knochensarkome  mit  Ostitis  deformans.  Chir.  Kongr.-Verhandl., 
1904,  II,  p.  424. — Reinhardt.  Sarkome  der  langen  Rohrenknochen.  Deutsche  Zeitschr. 
f.  Chir.,  Bd.  47,  1898,  p.  525.— Ribbert.  Beitr.  z.  Entstehung  d.  Geschwiilste.  Bonn, 
1906.— Schwimmer.  Remarks  on  Sarcoma  of  the  Skin  and  its  Varieties.  Internat. 
Congress  of  Dermatology  and  Syphilography.  Journal  of  Cutaneoiis  and  Genito-Uri- 
nary  Diseases,  1897,  April. — Weisswange.  Primare  Sarkome  der  Wande  der  Schiidel- 
hohle.     I.-D.     Tiibingen,  1897. 

(b)    SARCOMAS   COMPOSED   OF   CELLS  RESEMBLING   LYMPH 

CORPUSCLES 

The  term  lymphosarcoma  should  be  limited  to  those  tumors  Avhich 
have  their  prototype  in  or  develop  from  lym})hatic  tissue  proper  (lymph 
nodes,  follicles  in  mucous  meml)ranes  and  the  spleen).  The  term  should 
no  longer  be  applied  to  tumors  developing  fi-om  the  connective  tissue  or 
reticulum  of  the  lymphatic  nodes,  as  these  belong  to  the  librosarcomas. 

The  distinction  between  lymphosarcoma  and  hyperplastic  growths 
of  the  lymph  nodes  is  not  clear  and  sharp.     Lymphosarcomas  and  the 


864 


DIFFERENT   VARIETIES  OF   TUMORS 


specific  enlargement  of  lymph  nodes  first  descril)ed  by  Ilodokin  in  1^32, 
and  called  by  a  number  of  different  terms,  such  as  malignant  lymphoma 
(Billroth),  pseudoleukfemia  (Cohnheim),  adenie  (Trousseau),  aleukaemic 
malignant  lymphoma  (Orth),  are  often  grouped  under  some  generic 
term,  such  as  malignant  lymphoma  (Orth)  or  lymphocytoma  (Ribbert). 
Lymphosarcomas. — Lymphosarcomas  are  composed  principally  of  cells 
which  resemble  lymphocytes  (therefore  these  tumors  are  called  lympho- 

cytomas  by  Ribbert).  The  cells 
are  evenly  distributed  through- 
out a  vascular  reticulum  cov- 
ered by  endothelium.  The  struc- 
ture of  the  normal  lymph  node 
is  not  actually  reproduced,  as 
lymph  follicles  and  lymph  chan- 
nels are  wanting.  The  density 
of  the  reticulum  varies,  and  so 
a  distinction  is  made  between 
the  soft  and  hard  forms. 

These  tumors  always  develop 
from  normal  lymphatic  tissue, 
especially  from  the  lymph  nodes, 
the  cervical,  axillary,  retroperi- 
toneal, and  mediastinal  being 
most  frequently  involved.  They 
also  develop  from  the  palatal 
and  pharyngeal  tonsils,  the  lymphatic  follicles  of  the  gastrointestinal 
tract,  the  thymus  gland,  the  spleen,  and  bone  marrow. 

Age  at  Which  These  Tumors  Develop  and  Characteristics. — Lympho- 
sarcomas develop  most  frequently  in  young  people  from  lymph  nodes 
or  otlier  lymphatic  structures  to  form  rapidly  growing  tumors,  some- 
times soft,  at  other  times  hard,  which  rapidly  break  through  the  cap- 
sule of  the  lymph  node  and  extend  by  way  of  the  lymphatic  channels 
to  infiltrate  the  surrounding  tissues.  At  times  nodular  tumors  (which 
become  fused  with  neighboring  structures)  develop.  The  skin  covering 
the  tumor  may  also  become  infiltrated.  It  has  then  at  first  a  bluish 
color ;  later  it  becomes  necrotic,  and  large  ulcers,  which  may  also  become 
infected,  develop. 

Symptoms. — The  symptoms  produced  by  these  tumors  depend  en- 
tirely upon  their  position.  Mediastinal  tumors,  developing  from  the 
thyjrnis  gland  or  peribronchial  lymph, nodes,  will  compress  the  lungs  and 
heart;  tumors  developing  from  the  cervical  lymph  nodes  may  compress 
the  trachea  and  (esophagus.  These  tumors  frecpiently  cause  symptoms 
by  pressing  upon  adjacent  nerves  and  blood  vessels. 


Fig.  367. — Section  of  a  Lymphosarcoma  of 

THE     Nasal     Mucous     Membrane     from 

WHICH  MOST  OF  THE  CeLLS  HAVE  BEEN  RE- 
MOVED BY  Shaking,  a,  Reticulum;  h,  cells 
of  the  reticulum;  c,  round  cells;  d  (above 
and  to  the  left),  blood  vessel  lined  with  pro- 
liferating cells.     (After  Ziegler.) 


SARCOMAS 


865 


If  the  tumor  does  not  produce  early  death  by  pressure  upon  impor- 
tant organs,  but  continues  to  enlarge,  metastases  develop  by  way  of  the 
blood  stream  in  the  lungs,  spleen,  liver,  and  .skin.  These  metastatic 
growths  may  appear  as  well-defined  nodules  or  as  diffuse  infiltrations  of 
an  entire  organ,  sometimes  being  accompanied  by  alterations  in  the  com- 
position of  the  blood  (lymphu'mia).  There  are  also  cases  in  which  the 
entire  lymphatic  system  is  involved,  forming  transitional  stages  between 
leuka-mic  lymphoma  and  aleuka'mic  malignant  lymphoma  (vide  Coenen). 

Diag)iosis. — The  diagnosis  is  based  upon  the  rapid  growth  and  posi- 
tion of  the  tumor.  A  lymphosarcoma  cannot,  however,  be  differentiated 
from  other  forms  of  sarcoma  developing  from  lymph  nodes  or  from  a 


/ 


r 


Fig.  368. — Lymphosarcoma  of  the  Neck. 


sarcoma  of  the  soft  tissues.  In  a  lymphosarcoma  the  glands  become 
fused,  forndng  a  single  mass  in  which  the  separate  lymph  nodes  can 
no  longer  be  palpated,  and  the  tumor  breaks  through  the  capsule  in- 
vading the  skin  and  surrounding  structures,  while  in  Hodgkin's  disease 


866 


DIFFERENT   VARIETIES  OF  TUMORS 


the   glands   remain   isolated   and   there  is  no   extension   of  the   growth 
through  the  capsule  to  surrounding  tissues. 

Indications   for    Treatment. — Early    and    extensive    removal    of    the 
growth  is  indicated,  in  spite  of  the  fact  that  the  results  following  even 


I  I. 


;ii'.i. — -Lymphosarcoma  of  the  Neck  and  Left  Axillary  Fossa. 


the  most  radical  procedures  are  unsatisfactory,  as  recurrences  rapidly 
develop. 

Hodgkin's  disease  (malignant  lymphoma)  differs  from  lymphosar- 
coma, ('Specially  in  its  clinical  course. 

In  this  disease  also  there  is  a  proliferation  of  lymphatic  tissue,  espe- 
cially (»r  llie  lyiii|)lia1i('  nodes.  The  histological  changes  resemble  very 
eldsely  11ios(!  round  in  l>in|)liosai'eonia,  ex('ei)t  that  there  is  no  tendency 
to  disintegi'alioii. 

Clinical  Differences  between  Ilodgkin's  Disease  and  LympJwsarcoma. 
— As  the  disease  progresses  two  distinct  clinical  differences  between  it 


SARCOMAS 


867 


and  lymphosarcoma  may  be  noted:  (1)  In  Hodgkin's  disease  the  changes 
are  limited  to  the  lymph  nodes,  and  the  proliferating  lymphatic  tissue 
does  not  break  through  the  cajjsules  of  the  nodes  and  involve  neighbor- 
ing structures.  (2)  In  Hodgkin's  disease  there  is  a  progressive  and  suc- 
cessive involvement  .of  different  chains  of  Ijnnph  nodes,  including  the 
spleen,  and  in  rare  cases  the  bone  marrow. 

The  development  of  foci  in  the  liver,  lungs,  kidneys,  and  bone  mar- 
row would  seem  to  indicate  that  malignant  lymphoma  is  closely  related 


Fig.  370. — Lymphosarcoma  of  the  Neck.      Rapid  recurrence  following  operation. 
(From  Professor  Bevan's  Surgical  Clinic.) 


to  true  tumors.  It  cannot,  hoAvever,  be  dejiionstrated  that  these  new 
foci  are  of  metastatic  origin,  as  it  is  possible  that  they  may  have  devel- 
oped from  preexisting  lymphatic  nodules. 


868  DIFFERENT    VARIETIES   OF  TUMORS 

Lynipliatic  limkcTiiiia  may  resemble  malignant  lymphoma  quite 
closely,  as  in  this  disease  there  is  also  a  progressive  enlargement  of  the 
lymph  nodes  with  the  formation  of  so-called  heteroplastic  nodules  in 
different  organs.  A  blood  examination  enables  one  to  differentiate  be- 
tween the  two  very  easily,  as  in  lymphatic  leukeemia  the  leucocytes  are 
greatly  inci-eased,  reaching  150,000  or  more  per  cubic  millimeter,  and 
there  is  a  great  preponderance  of  lymphocytes  which  constitute  from 
ninety  to  ninety-nine  per  cent  of  all  the  cells,  while  in  malignant  lymph- 
oma the  number  of  leucocytes  is  normal  or  only  slightly  increased. 

Clinical  Course  and  Appearance  of  Lymph  Nodes. — Aleuka?mic  ma- 
lignant lymphoma  (Ilodgkin's  disease,  pseudoleuka?mia)  develops  most 
frequently  in  young  and  vigorous  people.  The  disease  begins  with  a 
gradual  painless  enlargement  of  the  lymphatic  nodes,  the  cervical  group 
being  most  frequently,  the  axillary  and  inguinal  less  often,  primarily 
affected.  The  separate  nodes  enlarge  to  form  soft  tumors,  if  there  is 
connective-tissue  induration  to  form  hard  ones,  the  size  of  a  walnut 
or  apple,  and  the  entire  chain  of  nodes  becomes  transformed  into  a 
nodular  mass.  The  nodes  are  homogeneous  and  grayish-red  in  color 
upon  section,  the  distinction  between  cortex  and  medulla  being  lost. 
There  is  no  tendency  to  regressive  changes  or  to  break  through  the  cap- 
sule of  the  lymph  nodes  and  invade  surrounding  tissues;  therefore  the 
separate  nodes  can  be  palpated  beneath  the  normal  skin  and  displaced 
upon  each  other. 

The  growth  is,  as  a  rule,  intermittent,  periods  of  rapid  growth  alter- 
nating with  periods  during  which  the  nodes  remain  stationary.  When 
the  i)i-oliferative  changes  extend  to  neighboring  nodes,  and  the  lymphatic 
tissues  of  the  pharynx,  gastrointestinal  tract,  spleen,  and  thymus  gland 
become  involved,  general  symptoms  may  develop.  These  consist  of  an 
intermittent  fever,  increasing  anamiia,  and  weakness.  Digestive  dis- 
turbances (vomiting,  diarrhea),  secondary  to  involvement  of  the  lym- 
phatic tissue  of  the  gastrointestinal  tract,  and  interference  with  respira- 
tion and  deglutition,  secondary  to  proliferation  of  lymphatic  tissue  of 
the  pharynx,  may  rapidly  increase  in  severity  and  cause  death,  which 
in  severe  eases  may  occur  in  a  few  months. 

Diagnosis. — The  diagnosis  is  difficult  so  long  as  a  single  chain  of 
lymph  nodes  is  affected.  An  examination  of  the  blood,  with  the  absence 
of  IIh'  characteristic  changes  of  leiika'iiiia,  and  the  fact  that  the  separate 
nodes  may  be  palpated  and  moved  freely  beneath  the  skin  and  upon 
each  other  ena])le  one  to  exclude  lymphatic  leuka'mia  and  lymphosar- 
cdiiia  i-cspcctively.  Tjyin])li  nodes  the  seat  of  giunmatous  lesions  are  hard 
and  soon  conti-ict  adhesions  with  the  su)"rounding  tissues  and  skin,  lead- 
ing to  the  foi-niation  of  quite  charactei-islic  ulcers.-  The  differential  diag- 
nosis between  malignant  lymphoma  and  tuberculous  lymph  nodes,  espe- 


SARCOMAS 


869 


cially  when  the  latter  are  small  and  their  characteristic  changes  but 
little  pronounced,  is  often  very  difficult. 

Tuberculous  lymph  nodes  are  more  common  in  the  young  and  are 
more  frequently  bilateral.  Regressive  changes  are  common  in  tubercu- 
lous nodes,  leading  to  the  formation  of  abscesses  and  fistulas.  The  ex- 
tent of  the  regressive  changes  varies,  but,  as  a  rule,  the  diagnosis  can 
be  made  even  before  the  nodes  have  contracted  adhesions  with  sui-round- 


FiG.  371. — Malignant  Lymphoma  in  a  Woman  Thirty  Years  of  Age.      (After  Dietrich.) 


ing  tissues  or  have  broken  down  to  form  tuberculous  abscesses.  There 
are,  however,  rare  forms  of  tuberculosis  of  lymph  nodes  in  which  the 
entire  lymphatic  system  is  involved  and  in  which  softening  does  not 
occur.  These  hyperplastic  forms  of  tuberculosis  resemble  very  closely 
malignant  lymphoma.  In  these  cases  a  differential  diagnosis  based  upon 
clinical   data  alone  is  impossible,   and  the  tuberculous  nature  of  the 


870  DIFFERENT   VARIETIES  OF   TUMORS 

lesions  can  be  determined  only  by  an  accurate  microscopical  examination 
(demonstration  of  bacilli  and  giant-cells). 

[Crowder  has  reported  an  exceedingly  interesting  case  of  generalized 
tuberculous  lymphadenitis  with  the  clinical  and  anatomical  picture  of 
Hodgkin  's  disease.  In  discussing  this  case  he  says :  ' '  The  great  number 
of  terms  applied  to  the  condition  designated  as  pseudoleukeemia,  based 
upon  the  somewhat  varied  clinical  course,  as  well  as  a  limited  variation 
in  the  gross  and  minute  pathological  changes  and  the  greatly  differing 
interpretation  of  these  changes  by  different  observers,  are  evidences  of 
the  heterogeneity  of  the  class  to  which  the  name  refers.  The  etiology  is 
for  the  most  part  admittedly  unknown;  it  is  also  admittedly  various. 
The  symptom  complex  determines  the  disease  as  the  disease  is  now 
understood.  Why,  then,  exclude  those  cases  in  which  the  tubercle  ba- 
cillus is  known  to  be  the  cause?  A  disease  of  known  origin  is  not  to 
be  singled  out  and  classed  as  a  different  disease,  but  as  an  etiological 
division  of  the  heterogeneous  class."] 

It  should  not  be  considered,  however,  that  there  is  any  relation 
between  hyperplastic  tuberculosis  of  lymph  nodes  and  Hodgkin 's  disease 
(Dietrich,  Borst),  even  if  cases  have  been  reported  in  which  the  changes 
occurring  in  malignant  lymphoma  have  been  associated  with  tuber- 
culosis of  the  lymph  nodes  and  viscera  (Ricker  and  others). 

Treatment. — No  attempt  should  be  made  at  radical  removal  of  the 
lymph  nodes,  even  in  the  beginning  of  the  disease,  as  there  is  a  great 
tendency  for  the  disease  to  recur  and  progress  in  other  chains  of  lymph 
nodes.  The  internal  administration  of  gradually  increasing  doses  of 
arsenic  in  the  form  of  Fowler's  solution  was  recommended  by  Billroth, 
and  in  some  cases  it  apparently  has  a  favorable  action.  Decrease  in  the 
size  of  the  lymph  nodes  and  improvement  of  the  general  condition  have 
been  noted  after  daily  injection  of  3  or  4  minims  of  Fowler's  solu- 
tion into  the  enlarged  lymph  nodes  (Czerny,  von  Winiwarter),  after  the 
injection  of  3  or  4  minims  of  a  one  per  cent  solution  of  sodium  arsenate 
into  the  subcutaneous  tissues  (von  Ziemssen),  and  the  use  of  the  X-rays. 
Permanent  recoveries  after  any  line  of  treatment  are  apparently  excep- 
tionally rare.  [A  number  of  these  cases  have  been  much  improved  by 
the  X-ray.  The  tumors  grow  smaller,  and  even  disappear  entirely.  The 
ti'catment  should  not  be  pushed  too  rapidly,  as  with  the  breaking  down 
and  absorption  of  the  tumor  masses  severe  and  even  fatal  toxaemia  may 
occur.] 

LiTRKATUUE. — Coeticn.  ITeber  cin  Lymphosarkom  dor  Thymus.  Arch.  f.  klin.  Chir., 
B(l.  7.'J,  1004,  p.  44.'{. — Dietrich.  Uobor  die  Bo/iehuiigeu  der  malignen  Lyin]>home  zur 
Tiilx-rkiilosc.  Bcitr.  z.  klin.  Chir.,  Bd.  16,  1896,  p.  377. — Fr.  Fischer.  Krankheiten  der 
Lyiiil)hgefii.sse,  Lymphdriisen  und  Blutgefasse.  Deutsche-Chir.,  1901. — Ricker.  Ueber 
die  Beziehungen  zwischen  Lymphosarkom  und  Tuberkulose.     Arch.  f.  klin,  Chir.,  B<i. 


SARCOMAS  871 

no,  ISO'),  p.  573. — Sternberg.  Universelle  Priiniirerkrankiinfijon  des  lyinphatischcn 
Ai)iiar:ites.  Zentralbl.  f.  <1.  Grenzgeh.,  18!M),  p.  G41. — Wilh.  Tiirk.  Pseutlolcukjimie 
uiid  Lymphosarkoniato.se.  Wien.  klin.  Wochenschr.,  1899,  No.  40. — v.  Winiwarter. 
l^eber  das  maligne  Lymphom  und  das  Lymphosarkoin.  Arch.  f.  klin.  Chir.,  Bd.  18, 
1875,  ]).  98. — Yamasaki.  Zur  Kerintnis  dor  Hodgkinschen  Krankheit  und  ihres  Ueber- 
ganges  in  Sarkom.     Zeitschr.  f.  Heilk.,  Bd.  25,  1904,  p.  209. 

Myelomas  and  Chloromas. — ^Myelomas  and  chloromas,  which  are  rare 
and  peculiar  forms  of  tumors,  should  be  classified  with  lymphosarcomas. 

Multiple  myelomas  are  rare.  They  appear  as  small,  nodular,  circum- 
scribed, soft,  grayish  red  growths,  especially  in  the  red  marrow  of 
different  bones.  They  are  regarded  by  some  as  lymphosarcomas,  by 
others  as  localized  hyperplasias  of  bone  marrow.  They  have  no  tend- 
ency to  infiltrate  surrounding  tissues  or  to  form  metastases,  but  remain 
limited  to  the  bones  primarily  involved.  The  bone  adjacent  to  a  mye- 
loma is,  however,  gradually  destroyed  and  deformities  of  the  spine, 
defects  in  the  skull  bones,  and  spontaneous  fractures  may  occur. 

The  disease  is  most  common  in  old  people.  Often  it  runs  a  rapid 
course  with  intermittent  fever  and  symptoms  of  a  severe  primary 
anaemia,  and  terminates  fatally. 

It  has  frequently  been  demonstrated  that  a  peculiar  product  known 
as  Bence- Jones 's  albumose  appears  in  the  urine  in  nuiltiple  myelogenous 
osteosarcomas  and  myelomas.  The  reaction  has  been  regarded  as  almost 
pathognomonic.  Askanazy  has,  however,  found  the  substance  in  the 
urine  in  a  case  of  lymphatic  leukaemia.  He  has  come  to  the  conclusion 
tliat  Bence- Jones 's  albumose  is  indicative  of  some  lesion  of  the  bone 
marrow,  most  frequently  of  multiple  myelomas,  but  also  occasionally 
of  other  diffuse  changes,  such  as  occur  in  lymphatic  leukaemia. 

Literature. — Hoffmann.  ITeber  Myelomatose,  Leukamie  und  Hodgkinische 
Krankh.  Arch.  f.  klin.  Chir.,  Bd.  79,  1906,  p.  ^S^.—Wielaml.  Studien  iiber  das 
priniiir  multipel  auftretende  Lymphosarkom  der  Knochen.  Virch.  Arch.,  Bd.  166, 
1901,  p.  103. — Winkler.  Das  Myelom  in  anatoniischer  und  klin.  Beziehung.  Virch. 
Arch.,  Bd.  161,  1900,  p.  508. — Yellinek^  Zur  klin.  Diagnose  und  path.  Anatomie  des 
niultiplen  Myeloms.  Virch.  Arch.,  Bd.  177,  1904,  p,  96. — v.  VereUly.  Ueber  das 
Myelom.     Beitr.  z.  klin.  Chir.,  Bd.  48,  1906,  p.  614. 

Chloromas  are  also  rare.  They  appear  as  multiple  new  gro"\\i:hs  com- 
posed of  lymphadenoid  tissue.  They  are  most  common  in  children  and 
young  people,  developing  as  firm,  more  rarely  soft,  tumors  from  the 
tlie  periosteum  of  the  bones  of  the  skull  and  face  (especially  from  the 
squamous  and  petrous  portions  of  the  temporal  bone,  the  maxilla  and 
orl)its  (both  orbits  usually  being  involved),  also  from  the  sternum,  ribs, 
vertebrae,  and  long,  hollow  bones.  They  resemble  quite  closely  very 
malignant  sarcomas,  in  that  they  grow  rapidly  and  form  metastases  in 
lymph  nodes  and  the  different  viscera,  but  differ  from  sarcomas  in  that 


872 


DIFFERENT    VARIETIES   OF   TUMORS 


the  tumors  have  a  bright  green,  yellowish,  or  grayish-green  color,  which 
is  also  reproduced  in  the  metastatic  growth.  According  to  von  Reck- 
linghausen, the  color  is  due  to  pigment  formed  by  the  cells;  according 
to  Chiari  and  Huber,  to  the  fat  contained  in  the  tumors. 

Literature. — Risel.  Zur  Kenntnis  des  Chloroms.  Deutsch.  Arch.  f.  klin.  Med., 
Bd.  72,  1902,  p.  31. — Rosenhlath.     Ueber  Chloroin  und  Leukamie.     Ibid.,  p.  1. 

(c)  SARCOMAS   COMPOSED   OF   MYXOMATOUS  TISSUE 

Myxomas  and  Myxosarcomas. — These  tumors  are  composed  of  soft, 
often  indistinctly  fluctuating,  gelatinous  masses  of  tissue.  Their  sur- 
faces upon  section  appear  yellow  or  grayish-red  and  transparent.  A 
tenacious  fluid  containing  mucin  and  permeated  by  delicate  fibers  may 
'be  removed  from  the  cut  surfaces  of  such  a  tumor. 

The  tissue  composing  these  tumors  closely  resembles,  histologically, 
embryonal  connective  tissue  from  which  white  fibrous  tissue  and   fat 


Fig.  372. — Myxosarcoma,     a,   Mj'xoinatoiis  tissuo;  b,  columns  of  cells;  c,  fibrous  tissue. 

(After  Zicgler.) 


arc  {'ormed.  It  has  its  prototype  in  Wharton's  jelly  and  the  vitreous 
humor. 

Ilislohxjjj. — 'i'he  structui-e  of  these  tumors  is  quite  characteristic, 
polyniorj)h()us,  stellate  cells,  provided  with  long  processes,  being  found 
within  a  homogeneous,  slightly  graindar  or  fibrillated  ground  substance, 
wliich  is  ti-aversed  by  a  relatively  large  number  of  blood  vessels.  Single 
giant-cells  may  be  found  in  some  parts  of  the  tumor. 

No  tumoj-  is  ever  composed  of  myxomatous  tissue  alone.    It  is  usually 


SARCOMAS 


873 


i 


found  in  combination  with  other  kinds  of  tumor  tissue,  especially  with 
fat,  cartilage,  tibrous,  and  sarcomatous  tissue.  For  this  reason  the 
tumors  are  called  lipomyxomas,  chondromyxomas,  Hbromyxomas,  and 
myxosarcomas.  If  the  tumor  contains  a  large  number  of  blood  vessels 
it  is  called  a  myxoma  teleangiectati- 
cum  or  cavernosum ;  if  the  tissues 
undergo  liquefaction  and  cyst  for- 
mation the  tumor  is  described  as  a 
myxoma  cysticum. 

Some  connective-tissue  tumors 
(fibroma  of  the  nasal  nnicous  mem- 
brane, pendulous  fibroma  or  lipoma 
of  the  surface  of  the  body)  may  be- 
come (edematous  as  the  result  of 
interference  with  their  circulation 
and  resemble  myxomatous  tissue, 
but  these  tumors  should  never  be 
classified  with  myxomas.  The  deli- 
cate but  distinct  fibrillar  ground 
substance,  together  with  the  micro- 
scopic mucin  reaction  (acetic  acid), 
are  the  important  characteristics 
of  myxomas.  Mucoid  degeneration 
may  occur  in  large  tumors,  such  as 
chondromas,  osteomas,  fibromas,  sar- 
comas, but  in  these  cases  there  is, 
strictly  speaking,  no  formation  of 
myxomatous  tissue.  In  order  to  sig- 
nify this  difference  between  the  two 
forms,  a  fibroma,  chondroma,  or 
other  tumor  which  has  undergone 
secondary  mucoid  degeneration  is 
called    a   fibroma-    or    chondroma- 

myxomatodes,  etc.,  while  a  tumor  which  is  composed  of  both  myxomatous 
or  fibrous  tissue  is  called  a  myxofibroma  or  fibromj'xoma. 

Origin,  Distribution,  and  Clinical  Course. — These  tumors  are  fre- 
quently of  congenital  origin.  This  indicates  that  they  are  the  result 
of  developmental  disturbances  occurring  in  embryonal  life.  Congenital 
tumors  of  this  character  have  been  observed  in  the  cheeks  by  Zahn,  in 
the  remains  of  the  umbilical  cord  by  0.  "Weber,  Kaufmann,  and  von 
Winekel,  and  in  the  mesentery  by  Borst.  The  displaced  embryonal 
myxomatous  tissues  do  not  always  form  myxomatous  tissue  only,  but 
fibrous  and  sarcomatous  tissues  as  well. 
56 


) 


Fig.  373. 


-Myxosarcoma  of  the  Fascia 
Lata. 


874 


DIFFERENT   VARIETIES   OF   TUMORS 


Myxomas  form  nodular  or  lobiilated  tumors  with  well-developed  con- 
nective-tissue septa.  These  tumors  often  attain  considerable  size.  They 
are  most  connnon  in  young  or  middle-aged  people,  and  their  rate  of 
growth  varies.     Some  of  these  tumors  have  an  expansive  growth  for  a 


Fig.  374. — Myxosarcoma  of  the  Fascia  of  the  Arm. 


long  time  or  permanently.  The  cellular  tumor  of  a  sarcomatous  nature 
grows  rapidly,  breaks  through  its  capsule,  infiltrates  the  surrounding 
structure  and  skin,  which  ulcerates,  and  forms  metastases.  Some  of 
these  tumors  are  benign  and  some  are  malignant ;  depending  upon  their 
character,  they  are  spoken  of  as  myxomas  or  myxosarcomas. 

These  tumors  may  develop  in  a  number  of  different  tissues  and  or- 
gans, occurring  most  commonly  in  the  cutaneous  and  subcutaneous,  inter- 
..  ___^  muscular  and  retroperito- 

.^'  " ,  neal  connective  tissues  and 

fat,  in  bursiP  and  fascia, 
the  periosteum  and  bone 
marrow,  the  membranes 
of  the  brain  and  spinal 
cord,  the  connective  tissues 
of  the  nervous  system  and 
different  organs  (mam- 
mary gland,  ovary,  tes- 
ticle, and  spermatic  cord, 
kidneys,  liver,  and  lung). 
They  are  most  frequently  found  in  tiie  thigh,  developing  from  the 
skin,  the  subcutaneous  and  intermuscular  connective  tissues,  the  fascia 
and  the  bursa*  about  the  knee  joint,  less  frequently  upon  the  arm  and 
in  the  gluteal  region.  They  occur,  when  they  develop  upon  the  external 
genitalia,  the  neck,  face,  and  scalp,  as  subcutaneous  tumors.  In  the 
oi'bit   tliry  flcvclop  Troiii  the  retrobulbar  fat  or  the  oi)tic  nerve.     Myxo- 


FiG.  375. — Myxoma  of  the  Radiat^  Nerve  in  a  Man 
Thirty-five  Years  of  Age.  Resection  followed  by 
nerve  suture.  Healing  with  complete  rctiu-n  of  fune- 
tion.      No  recurrence  after  five  vears. 


SARCOMAS 


875 


mas  of  the  peripluTMl  nerves,  like  fibromas,  may  occur  as  multiple 
tumors.  When  deveh)pinj2:  upon  the  nerves,  they  separate  the  nerve 
fibers  and  cause  fusiform  thicken  in, us  of  the  nerve  trunks.  In  children 
these  tumors  may  deveh)p  from  the  remains  of  the  umbilical  cord. 

Myxomas  of  the  bone  mai-row,  which  usually  are  cystic,  may  cause 
pressure  necrosis  and  destruction  of  the  compact  bone  surrounding  them. 
Periosteal  myxomas  occur  ui)on  both  the 
maxilla  and  mandible,  usually  in  the  form 
of  encapsulated  filu'ous  tumors.  Tumors 
occurring  within  the  jaw  luay  develop 
from  tooth  buds,  so  long  as  they  consist  of 
myxomatous  tissue,  and  appear  as  a  variety 
of  odontoma.  Myxomas  of  the  endocar- 
dium have  a  special  significance.  They 
appear  as  lobulated  tumors,  developing 
into  the  left  auricle  from  the  interauricu- 
lar  septum.  More  rarely  they  are  situated 
upon  the  valves.  Small  pieces  of  these 
tumors  may  become  separated,  causing 
embolism  (yiVie  Jacobsthal).  IMyxomatous 
tissue  is  also  frequentl}^  found  in  mixed 
tumors,  especially  in  those  occurring  in  the 
parotid  gland. 

Naturally,  the  clinical  symptoms  caused 
by  these  tumors  depend  upon  their  posi- 
tion, the  character  of  their  growth,  and  the 
size  they  attain. 

Diagnosis. — These  tumors  have  a  char- 
acteristic consistency,  and  the  diagnosis  is 
not  difficult  if  they  have  grown  rapidly 
and  infiltrated  the  tissues.  The  consist- 
ency, combined  with  the  character  of  the 
growth,  generally  enables  one  to  make  a 
diagnosis  of  a  myxosarcoma.  The  diag- 
nosis is  more  difficult  if  the  tumor  is 
encapsulated,  as  then  a  myxoma  may  re- 
semble a  tuberculous  abscess,  a  lipoma,  or 
any  variety  of  cyst.  Sometimes  aspira- 
tion reveals  a  small  amount  of  fluid  con- 
taining delicate  fibrilhe,  and  in  that  event  raiuiia,  hygromas,  and  cysts, 
which  may  contain  mucoid,  gelatinous  masses,  must  be  excluded.  As 
a  rule  this  can  easily  be  done,  when  the  position  of  the  tumor  is 
considered. 


Fig.  37G. — Rethoi'eritoneal  Myx- 
osarcoma AND  Intermuscular 
Myxosarcoma  of  the  Gluteal 
Region  (not  Connected  with 
Nerves).  Multiple  soft  fibroma 
of  the  skin  and  many  pigmented 
moles. 


876  DIFFERENT   VARIETIES   OF   TUMORS 

Treatment. — The  treatment  to  be  instituted  depends  upon  whether 
the  tumor  is  encapsulated  or  not,  and  upon  whether  it  has  grown  slowly 
or  rapidly.  If  the  tumor  is  encapsulated  and  has  grown  slowly,  enuclea- 
tion is  all  that  is  required.  If,  on  the  other  hand,  the  tumor  has  grown 
rapidly  and  infiltrated  surrounding  structures,  a  radical  operation  must 
be  performed.  In  tumors  of  the  extremity  an  amputation  may  be  neces- 
sary. If  a  myxoma  develops  upon  a  nerve,  the  latter  should  be  resected 
and  nerve  suture  performed,  if  the  tumor  cannot  be  enucleated.  In 
myxomas  of  the  optic  nerve,  the  bulb  of  the  eye  may  be  retained,  unless 
the  tumor  has  already  extended  to  it. 

Literature. — Jacohsthal.  Primares  Fibromyxom  des  linken  Vorhofs.  Virch. 
Arch.,  Bd.  159,  1900,  p.  351. — Orth.  Schleiin  und  Schleimgeschwiilste.  Gcsellsch.  d. 
Wissensch.  zu  Gottingen,  1895. — Rumler.  Ueber  Myxom  und  Schleimgewebe.  I.-D., 
Bonn,  1881. — -v.  Winckel.  Ueber  angeborene  solide  Geschwiilste  des  perennierenden 
Teiles  der  Nabelschnur.  v.  Volkmanns  Samml.  klin.  Vortr.,  No.  140,  1895. — Zahn. 
Ueber  ein  Myxosarkom  bei  einem  6monatl.  Kinde,  hervorgegangen  aus  dem  Saugpolster 
der  linken  Wange.     Deutsche  Zeitschr.  f.  Chir.,  Bd.  22,  1885,  p.  387. 

(d)  SARCOMAS   COMPOSED   OF   PIGMENT   CELLS 

Melanosarcomas. — Sarcomas  composed  of  pigment  cells  are  called 
melanomas  (malignant  melanomas,  melanosarcomas,  chromatophoromas). 

Most  Important  Characteristics. — The  most  important  characteristics 
of  these  tumors,  which  occur  primarily  only  in  the  eye  and  skin  and 
the  adjacent  mucous  membranes,  are  their  color  and  malignancy.  De- 
veloping at  any  age,  they  form  round,  nodular,  pedunculated  or  fungi- 
form growths  which  in  the  beginning  are  covered  by  a  delicate  epider- 
mis but  soon  ulcerate.  They  are  very  vascular,  bleeding  easily,  and  are 
covered  with  crusts  or  become  transformed  into  craterlike  ulcers.  The 
floor  of  the  ulcer,  which  is  black  or  brownish  black  in  color,  appears  as 
if  filled  with  india  ink  and  secretes  a  serohamiorrhagic,  usually  black, 
fluid. 

The  consistency  of  these  tumors  varies ;  sometimes  they  are  hard,  at 
other  times  soft.  The  color  of  the  tissues — which  varies  between  a 
l)hu'k  and  yellowisli-ln-own  shade,  is  fi-('({uently  apparent  upon  the  sur- 
face, and  can  always  be  seen  after  section — indicates  the  character  of 
the  tumor.  The  pigment  is  either  distributed  evenly  throughout  the 
tumor  tissues  or  occurs  in  areas  which  nuiy  be  surrounded  by  tissues 
absolutely  devoid  of  pigment.  IlaMnorrhagic  foci,  which  are  frequent 
ill  tumors  of  lliis  clinracter,  may  be  distinguished  from  the  pigmented 
liiiiKif  1  issue  by  llicir  dark,  brownish-red  color. 

Iicgrcssivc  cliaiigcs  in  tlu;  tmiior  tissue,  ending  in  li(iuefaction,  lead 
to  the  foriiiation  of  large  cavities  filled  witli  black-fluid. 

Melanomas  of  the   eye  develoi)    I'l-oiii    llie   choroid,   the  iris,   or  pig- 


SARCOMAS 


877 


mented  areas  along  the  margin  of  the  conjunctiva.    Melanomas  develop- 
ing in  the  eye  grow  rapidly  after  rupture  of  the  sclera  or  cornea,  de- 
stroying the  bulb,  and  form  large,  nodular,  pigmented  growths,  which 
protrude   from   the  orbit  or  extend   into   the 
cranial  cavity. 

^lost  of  the  melanomas  developing  in  the 
skin  begin  in  congenital  pigmented  areas  or 
in  wartlike  moles.  When  they  develop,  there 
appears  at  the  site  of  the  mole  a  brownish  or 
brownish  black  nodule,  which  in  the  beginning 
develops  slowly,  sometimes,  however,  after  some 
irritation,  such  as  cauterization,  very  rapidly. 
The  surface  of  the  nodule  ulcerates,  becomes 
fissured,  and  bleeds  easily.  The  primary  tu- 
mor may  scarcely  have  reached  the  size  of  a 
walnut  when  small,  secondary  nodules,  which 
appear  as  small  bluish  points,  develop  in  the 
skin  surrounding  the  tumor.  These,  as  they 
enlarge,  fuse  with  the  primary  growth,  con- 
tributing in  this  way  to  its  rapid  increase  in 
size. 

Early  Involvement  of  Lymph  Nodes. — The 
regional  lymph  nodes  enlarge  early,  and  upon 
section  black  or  brown  areas,  corresponding  to 
metastatic  growths,  may  be  seen.     Alteration 

of  the  functions  of  the  viscera,  general  Aveakness,  and  an  increasing 
anamiia  indicate  the  formation  of  metastatic  growths  by  way  of  the 
blood  stream.  Extensive  metastases  develop  exceedingly  rapidly  and 
make  melanomas  the  most  malignant  of  all  tumors. 


Fig.  377.  —  Melanosarcoma 
OF  THE  Foot  in  a  Man  Fifty 
Years  of  Agf..  Small  sec- 
ondary nodules  may  be  seen 
in  the  skin  surrounding  the 
primary  tumor. 


Fig.  378. — Melanosarcoma  op  the  Foot  in  a  Woman  Forty-five  Years  of  Age. 


3Iost   Common  Sites  for  Development. — As  pigmented   moles  may 
occur   ui)on   any   part   of   the  skin,    so    melanomas    may    develop    any- 


878 


DIFFERENT   VARIETIES   OF   TUMORS 


Fig.  379.  —  Melanoma 
OF  THE  Tip  of  the 
Finger. 


where  upon  the  surface  of  the  body.  They  develop  most  frequently, 
however,  in  the  skin  of  tlie  face  and  of  the  extremities.  In  the  ex- 
tremities, the  flexor  surfaces,  the  bed  of  the  nail  and  tlie  tissues  ad- 
jacent to  it  tire  most  com- 
monly involved  (Fig.  379). 
In  rare  cases  these  tumors 
develop  in  the  mucous  mem- 
brane of  the  rectum,  nose, 
and  soft  palate.  It  is  doubt- 
ful whether  the  arachnoid 
and  pia  mater  are  ever  pri- 
marily involved,  for  second- 
ary nodules  may  develop  in 
those  membranes  many  years 
after  an  eye,  the  seat  of  such 
a  tumor,  has  been  enucleated 
(Dobbertin),  and  unless  an 
accurate  history  can  be  ob- 
tained, secondary  nodules  may 
be  regarded  as  a  primary 
tumor. 

Character  of  the  Pigment. — T.he  pigment  melanin  occurs  as  a  granu- 
lar or  lumpy  brown  mass  within  the  cytoplasm,  and  is  to  be  regarded 
as  a  product  of  secretion  of  the  cells.  Usually  the  pigment  lies  around 
the  periphery  of  the  cell  body.  If  regressive  changes  occur,  the  pig- 
ment is  set  free  and  is  then  taken  up  by  wandering  cells  to  be  trans- 
ferred to  other  parts  of  the  tumor  (Borst). 

Origin  of  Melanosarcomas  and  Nature  of  Cells. — It  is  probable  that 
melanomas  develop  from  displaced  groups  of  pigment  cells.  The  occur- 
rence of  these  tumors  in  the  sclera  and  retrobulbar  fat  may  be  satisfac- 
torily explained  in  this  way.  Another  fact  Avhich  supports  this  theory 
is  that  melanomas  of  the  skin  develop  in  congenital  pigmented  nffivi. 
Therefore  there  must  be  some  relation  between  the  cells  composing 
iiiiljiiiuinas  and  those  found  in  pigmented  nasvi.  Naevi  contain  pigment 
cells  in  the  lower  layers  of  the  epidermis;  well-developed  ehromatophores 
in  the  eorium,  which  is  thickened  in  the  warty  forms;  and  groups  and 
f'()liiiiiiis  of  round  or  oval  nonpigmented  cells,  the  significance  of  which 
has  been  differently  interpreted.  These  cells  have  been  regarded  as 
epithelium,  as  endothelium  of  the  lymphatic  spaces,  and  as  connective- 
tissue  cells,  which  were  related  to  the  cutaneous  nerves.  Ribbert  be- 
lieves that  they  are  genetically  ehromatophores  which  have  not  gone  on 
to  complete  differentiation   (without  ])igment). 

According  to  Virchow,  melanotic  tumors  are  composed  of  groups  of 


SARCOMAS  879 

cells  which  carry  pigment,  and  only  after  regressive  changes  is  the  pig- 
ment found  without  the  cells.  According  to  Kil)bert,  the  cells  found 
in  melanomas  belong  to  a  definite  type,  the  pigmented  connective-tissue 
cell  or  chromatophore ;  therefore,  the  term  chromatophoroma. 

The  pigment  cells  found  in  a  melanoma  of  the  bulb  differ  in  early 
stages  of  the  growth  very  little  from  the  normal  chromatophores,  as 
they  occur  in  the  choroid,  the  iris,  and  in  pigmented  areas  in  the  skin, 
such  as  the  nipple,  the  skin  about  the  anus,  and  in  congenital  pigmented 
moles.  Elongated  cells  with  long  processes  lie  close  together,  arranged 
in  bundles,  and  the  tissue  resembles  histologically  a  spindle-cell  sarcoma. 
If  a  rapidly  growing  tumor  of  the  choroid  breaks  through  the  sclera, 
it  assumes,  according  to  Ribbert,  the  structure  common  to  melanomas 
of  the  skin.  In  these  cases  normal  chromatophores  can  be  demonstrated 
only  in  fresh  preparations.  Upon  microscopic  examination  of  these 
rapidly  growing  tumors  of  the  choroid  and  of  melanomas  of  the  skin, 
large  round,  spindle,  and  polymorphous  cells  with  short  processes  are 


Fig.  380. — Metastases  (from  a  Melanosarcoma)  in  the  Small  I.n  usi  i.m;  and  .Mksentery. 


found.  Some  of  these  contain  pigment,  while  others  are  pigment  free. 
According  to  Ribbert,  these  differences  in  the  cells  are  dependent  upon 
different  degrees  of  development.  He  regards  the  cells  without  pig- 
ment as  young  forms,  the  large  round,  heavily  pigmented  cells  as  de- 
generating forms,  and  the  other  cells  as  more  or  less  well-developed 
cells,  which  resemble  epithelium  and  lie  within  a  fibrillar  network. 
Upon  microscopic  examination  an  alveolar  arrangement  is  seen.  The 
blood  vessels  lie  within  this  fibrillar  network.  The  cells  which  contain 
the  most  pigment  are  adjacent  to  them.  The  last  fact  is  the  more 
striking  as  the  cells  lying  in  the  pseudo-alveoli  usually  are  pigment  free, 
being  pigmented  in  the  very  dark  tumors  only.  Fine  fibrilla'  from  the 
bundles  of  fibers  pass  between  the  different  cells.     It  is  important  to 


880 


DIFFERENT   VARIETIES   OF   TUMORS 


determine  whether  the  fibrilUx'  are  processes  of  the  pigmented  cells, 
for  if  they  are,  it  speaks  against  the  origin  of  melanomas  from  pig- 
mented epithelial  cells  of  the  skin  and  retina.  [Notwithstanding  the 
number  of  investigations  that  have  been  made  regarding  the  origin  of 
chromatophores,  there  is  but  little  uniformity  of  opinion  at  the  present 
time  as  to  whether  they  are  derived  from  mesoblast  or  epiblast.  Many 
pathologists  now  follow  Unna  and  regard  the  cells  found  in  melanomas 
as  derivatives  of  down  growths  of  surface  epithelium  and  classify  the 
tumors  as  carcinomas.  These  tumors  should  probably  be  called  melano- 
carcinomas  instead  of  melanosarcomas.]  Clinically,  these  tumors  differ 
in  some  ways  from  sarconuis,  probably  the  most  striking  difference  being 
the  frequency  with  which  they,  like  carcinomas,  form  metastases  by  way 
of  the  lymph  stream. 

It  is  not  clear  in  what  way  melanomas  develop  from  pigmented  naevi. 
According  to  Ribbert,  they  develop  only  from  chromatophores.  Others 
believe  that  they  develop  from  groups  of  mevus  cells.  Krompecher 
believes  that  they  develop  from  the  basal  cells  of  the  epidermis,  which, 
he  thinks,  may  also  proliferate  to  form  nsvus  cells. 

It  is  a  striking  fact  in  animal  pathology  that  melanomas  are  very 
common  in  white  horses.     This  can  only  be  interpreted  as   indicating 

that  irregularities  in 
the  distribution  and 
arrangement  of  pig- 
ment cells,  resulting 
in  tumor  formation, 
are  more  common  in 
those  animals  in  which 
t3/'  J^i^^^^^B^^^^}^^''^^W'^     ^^^^   pigmentary   proc- 

^^  Jr'/yJ.^Jn^il^^^^^^HKH^ftillt    ''^Ilf>^      esses  and  changes  are 

most  marked. 

3Iode  of  Growth: 
Meiastases.  —  Melano- 
mas, which  usually 
ai'c  coiiiposiHl  of  poor- 
ly differentiated  ele- 
ments, alwaj^s  have  an 
infiltrating  growth, 
the  cells  invading  the 
tissue  spaces.  The 
lymphatic  vessels  and 
blood  vessels  arc  fi'e(iueiitly  involved,  and  the  lumina  of  the  vessels 
adjacent  to  the  tumor  may  be  iilled  for  some  distance  with  proliferat- 
ing cells. 


m<<i 


(-1) 


II'  Nodule  in  tiho  KirncriAN'Koii: 
from  tlie  priuuiry  tumor). 


1''at 


SARCOMAS  SSI 

The  cells  invade  tlu'  iymphatics  .surrounding-  the  tumor,  leading:  to 
the  formation  of  small  secondary  nodules.  Not  infrequently  secondaiy 
nodules  are  encountered  in  the  subcutaneous  tissues  during  the  excision 
of  a  melanoma.  If  these  are  found,  the  excision  nuist  be  carried  well 
beyond  the  apparent  boundaries  of  the  tumor  into  healthy  tissues.  The 
tumor  cells  are  fre(iuently  carried  by  the  lymphatic  vessels  to  the  re- 
gional lymphatic  nodes,  which  become  enlarged,  forming  large  nodular 
tumors.  In  melanoma  of  the  bulb  of  the  eye,  the  first  metastases  fre- 
quently develop  in  the  brain. 

The  invasion  of  the  blood  vessels  is  followed  by  embolism  and  the 
development  of  extensive  metastases.  In  some  cases  so  many  emboli 
are  discharged  that  pigmented  tumor  cells  may  be  easily  demonstrated 
in  the  capillaries  and  in  the  larger  vessels  of  the  viscera,  especially 
in  the  liver.  The  metastases  developing  in  a  melanoma  ma,y  be  very 
extensive,  appearing  as  closely  grouped  nodules,  not  only  in  one,  but 
in  many  or  all  of  the  organs  (lungs,  liver,  spleen,  kidneys,  brain,  heart, 
intestinal  wall,  serous  membranes,  bone  marrow,  skin).  Besides  there 
may  be  an  extensive  discoloration  of  the  skin  and  nnieous  membranes 
(melanosis). 

The  amount  of  pigment  contained  in  the  metastatic  growths  varies. 
Adjacent  to  dark,  black  foci,  may  be  areas  and  nodules  Avhich  contain 
little  or  no  pigment.  A  rapid  proliferation  of  the  cells  is  associated 
with  a  decrease  in  the  amount  of  pigment  formed. 

The  pigment  set  free  when  regressive  changes  occur  in  a  melanoma 
may  gain  access  to  the  blood  stream.  Part  of  the  pigment  is  deposited 
in  the  different  organs,  and  part  is  dissolved  to  be  excreted  in  the  urine 
(melanuria),  which  then  assumes  a  dark  color. 

Clinical  Course. — The  clinical  course  of  mclauoinas  depends  ui)on 
their  rapidity  of  growth  and  upon  the  number  of  metastases  which 
form.  Non-operated  cases  die  in  a  short  time  t)f  antemia,  metastases 
and  general  infections  developing  from  ulcerating  and  infected  tumors. 
Recurrences  are  very  freciuent  after  operation.  The  early  development 
of  metastases  after  an  operation  indicates  that  emboli  had  lodged  in  the 
different  viscera  before  the  operation  was  performed.  A  fatal  termi- 
nation may  at  least  be  delayed  liy  the  removal  of  the  tumor,  and  some- 
times the  first  metastases  develop  years  afterwards  (Dobbertin).  A 
permanent  cure  can  be  expected  only  when  the  operation  is  performed 
very  early. 

Diagnosis. — The  diagnosis  of  melanomas  in  the  early  stages  may  offer 
some  difficulties.  A  melanoma  should  never  be  mistaken  for  a  benign 
tumor,  as  the  former  grows  rapidly.  A  vascular  sarcoma  with  exten- 
sive hfemorrhages  may  resemble  a  melanoma  macroscojiically,  but  a 
microscopic  examination  enables  one  to  differentiate  between  the  two. 


882  DIFFERENT   VARIETIES   OF   TUMORS 

Indication  for  Treatment. — The  indication  for  treatment,  taking  into 
consideration  the  malignancy  of  these  tumors,  is  to  remove  the  growth 
as  early  and  thoroughly  as  possibl(^  The  regional  lymphatic  nodes 
should  be  removed,  even  if  not  enlarged.  [It  should  be  remembered 
that  melanomas  form  early  and  extensive  lymphatic  metastases,  differ- 
ing in  this  respect  from  other  forms  of  sarcomas,  and  that  if  the  opera- 
tion is  to  be  at  all  successful  the  lymphatic  nodes  draining  the  primary 
tumor  must  be  radically  removed.] 

In  a  melanoma  of  the  bulb  of  the  eye,  the  contents  of  the  orbit 
should  be  removed,  even  if  the  growth  is  still  confined  to  the  eye.  In 
a  melanoma  of  the  skin,  excision  should  be  carried  wide  of  the  tumor 
into  healthy  tissues  and  down  to  muscle.  If  the  tumor  occurs  upon  the 
extremity,  amputation  at  some  distance  from  the  growth  should  be  per- 
formed, unless  there  are  contraindications. 

Naevi. — The  classification  of  ntevi  is  still  a  mooted  question.  Von 
Recklinghausen  and  Ziegier  regard  them  as  pigmented  forms  of  lymph- 


:5S2. N.K\rS    I'uiMF.NTOSt'S    I'lHISUS. 


iiiiuiomas.  Utma  and  others  regard  them  as  epilhclial  tumors.  Borst 
classifies  them  Jis  melanotic  fibromas.  FolloAving  Kibbert's  example,  we 
will  classify  them  under  melanomas.  There  are  several  reasons  justify- 
ing this  classification.    In  the  first  place,  melanomas  frequently  develop 


SARCOMAS 


883 


frciiii  pigmented  na-vi,  and  tlic  fact  that  ])ntli  may  ho  pigmented  indi- 
cates that  there  is  a  certain  rehdionsliip  l)etween  the  two. 

Pigmented  mevi  may  appear  in  a  number  of  different  forms,  between 
which  there  may  be  a  number  of  transitions. 

Naevi  Spili. — The  flat  nan'i  (nani  spili)  appear  as  sharply  defined, 
irreguhir,  coffee-brown  or  black  areas  in  the  skin,  varying  in  size  from 


Fig.  383. — N^vus  Pig.mexto.su6  YKiinn<»i 


the  head  of  a  pin  to  a  sancer.  They  are  covered  by  a  smooth  epidermis 
and  do  not  extend  above  the  level  of  the  skin.  They  are  very  similar 
in  gross  appearance  and  in  strnctnre  to  lentigines  and  freckles,  the 
latter  developing  upon  the  face  and  the  dorsum  of  the  hands  after 
exposure  to  the  sun's  rays.  The  flat,  smooth  na?vi  may  be  associated 
with  elephantiasis  of  the  nerves,  and  may  then  be  distributed  with  con- 
siderable regulai'ity  over  the  entire  surface  of  the  body  {vide  p.  794). 
Naevi  Prominentes. — The  elevated  na?vi  (nand  prominentes)  are  like- 
wise sharply  defined.  They  occur  as  deeply  pigmented,  beetlike,  soft 
growths,  which  often  become  very  large.  In  some  cases  they  may  ex- 
tend over  the  entire  trunk.  Their  surfaces  may  be  either  smooth  and 
shining,  or  covered  with  shallow  furrows,  corresponding  to  folds  in  the 
skin,  or  with  a  thick  hair  and  warty  growths.  The  following  forms 
are  differentiated,  depending  upon  the  character  of  the  surface  of  the 
nasvus:  (a)  Hairy  moles  (nievi  pilosi,  Fig.  382)  are  covered  by  a  thick 


8S4 


DIFFERENT   VARIETIES   OF   TUMORS 


growth  of  shdrt  dark  hair,  which  is  sonietiiuos  soft,  at  other  times  stilY. 
The  hair,  togetlier  with  the  brown  diseoloration  of  the  mole,  is  suggest- 
ive of  an  animal's  hide.  (6)  Warty  na?vi  (nievi  verrucosi,  papilloma- 
tosi)  are  covered  by  warty  growths.     They  appear  either  as  small,  soft, 

or  if  cornification  is  marked, 
as  hard,  round  or  peduncu- 
lated nodules,  or  as  long, 
thorny  papilla^  (Fig.  383). 
The  papillomatous  growths 
often    develop    later   upon    a 

f_,^___.  a^  preexisting  na^vus. 

i|#^  '■***3lpw  Origin  of  Pigmented  NcEvi. 

^        i-^rifeM    '^^^'  \         — Pigmented   ntevi    are    of 
^A^jB  f        \        congenital   origin,   or   appear 

i     m^tm  f         1     shortly  after  birth.    They  en- 

„^     WSoKm  .*-~-.«r     large  slightly  and  slowly  until 

the  full  growth  of  the  indi- 
vidual is  attained,  and  then 
they  remain  of  the  same  size 
and  form.  AVarty  growths 
may,  however,  develop  upon 
a  naevus  in  later  life  (Fig. 
384). 

They  may  occur  upon  any 
part  of  the  surface  of  the 
body,  frequently  being  mul- 
tiple (Fig.  385).  They  cause 
no  symptoms. 
In  many  cases  na-vi  occur  along  the  course  of  cutaneous  nerves,  hav- 
ing a  unilateral  or  symmetrical  distribution  (nerve  navi,  neuropathic 
papilloma,  occurring  especially  in  the  face  and  neck),  or  in  the  folds 
and  growths  of  skin  covering  plexiform  neuromas  and  superficial  neuro- 
fibromas. Flat  naivi  are  also  frequently  associated  with  soft  warts  and 
fibromas  of  the  skin,  being  distributed  over  the  entire  surface  of  the 
body.  All  these  facts  seem  to  indicate  that  naevi  have  some  relation 
to  nerves.  Their  relation  to  cutaneous  nerves  and  neurofibromas  is 
not  clear.  Soldan  regards  naevi  as  fibromas  of  the  most  delicate  cuta- 
neous nerves,  but  his  findings  have  not  as  yet  been  verified. 

Histology  of  Ncevi. — TTistologically,  the  elevated  na^vi  are  composed 
of  the  proliferated  connective  tissue  of  the  cutis,  especially  of  the  pa- 
pilla?, which  are  no  longer  well  defined  against  the  subcutaneous  tissues. 
The  epidcDiiis  is  also  involved  in  the  growth,  so  that  pigmented  najvi 
ai'e  closely  related   lo  (ihrocpithdinl  tuiiioi's. 


Fig.  384. — Congenital  Hairy  N^vus.  In  the  up- 
per parts  of  the  njevus  papillary  growths,  which 
have  been  developing  for  some  j^ears,  may  be 
seen. 


-*«*- 


%«, 


M- 


I'LA'i'K    1 


1.     Fl.AT     IMcMKXTr.l) 
XyEVlS. 

(a)  Groups  nf  ua'- 
vus  cells  and  cliro- 
iiiatophorus  in  the 
ccnuiective  lissiu'. 

(ft)  Groups  of  pif^- 
mcnt  colls  witliiii 
and  l)cnca1  li  llic  epi- 
dermis. 


#%>?<%  ^ 


&i 


V        ^^ 


y 


if. 


«*'  \^  -^  '^t0c'- 


/^* 


X 


/ 


■^z 


2.   ALVKoi.Aii  Mela- 
noma OF  THE  Skix. 


.A^i^o 


3.    i\lixi;n    Tumor 
oi'"    Tiiio    Parotid 

(il.AXl). 

(^0  Cartilage. 

{b)  Stroma  rcseui- 
l)ling-  fibrous  tissue. 

((/)  Coliiuuis  of 
epitiu'lial  colls  wilii 
filandliUo  structure 
and  hyaline  con- 
tents. 

{()  Interstitial 
s)il)stance  rosem- 
i)lini>-  a  sai'coimi. 


SARCOMAS 


885 


The  piiiiiicnt  lies  in  tine,  granular,  brownish  masses  in  tlie  oylin- 
drieal  cells  of  the  stratuni  penninativnni  and  in  the  large  chromato- 
phores  distributed  throughout  the  corium.  AVithin  the  proliferated  con- 
nective tissues  of  the  cutis  are  found 
groui)S  and  colunnis  of  round  or  oval 
cells,  the  so-called  ncEViis  cell  cluslcrs. 
These  cells,  together  with  the  pig- 
ment cells,  are  the  most  important 
constituents  of  the  fiat  nievi.  Accord- 
ing to  von  Recklinghausen,  Ziegler, 
and  Borst,  the  so-called  mevus  cells 
are  the  proliferated  endothelium  of 
the  lymphatic  vessels ;  according  to 
Ki])bert,  they  are  imperfectly  dilfer- 
entiated  chromatophores  surrounded 
by  a  fine  fibrillar  network.  Soldan 
regards  them  as  connective-tissue 
cells.  jMarchand,  Orth,  Unna  and  his 
school  believe  that  these  cells  are  of 
epithelial  origin,  while  Krompecher 
believes  that  they  are  derived  from 
the  basal  cells  of  the  epidermis. 
These  groups  of  cells  often  occur  in 
columns,  or  are  radially  arranged, 
passing  toward  the  surface  of  the 
nsevus.  In  the  deeper  parts  the 
groups  of  naevus  cells  are  closer  to- 
gether than  they  are  near  the  epi- 
dermis, upon  the  cells  of  which  they 
may  rest. 

Diagn osis.  —  The  diagnosis  of 
pigmented  nsvi  may  be  made 
without  any  difficulty.  The  pro- 
jecting forms  often  suggest  that  a 
plexiform  neuroma  may  be  pres- 
ent in  the  deeper  tissues  (vide  p. 
794). 

Treatment.  —  Nana  are  removed 
especially  for  cosmetic  purposes,  and 
then,  as  a  rule,  only  when  they 
occur  upon  the  face  and  neck.     In 

removing  a  nawus  the  skin  surrounding  it  sho\Ud  be  circuiuseribed  and 
then  dissected  away  from  the  subcutaneous  tissues.     If  the  defect  is 


**^. 


Fig.  38").  A  Y.i  w  w  Eighteen 
Years  of  Age  with  MuLTirLE  N^vi 
AND  AN  Elevated,  Hairy  Verrucous 
N^vu.s  WHICH  Involves  the  Left 
Cheek,  Scalp,  and  Neck. 


886  DIFFERENT   VARIETIES   OF   TUMORS 

so  large  that  the  wound  cannot  be  closed  by  sutures,  it  should  be  cov- 
ered by  skin  grafts.  Pedunculated  flaps  should  not  be  used  unless  it  is 
absolutely  necessary,  for  they  leave  disfiguring  scars  and  large  secondary 
defects.  Epidermal  strips  should  not  be  used  in  skin-grafting  these 
defects,  as  disfiguring  tuniorlik-e  masses  of  scar  tissue  may  form  which 
are  less  desirable  than  the  nivvus.  If  a  single,  large,  non-pedunculated 
cutis  flap  is  used  a  beautiful  result  may  be  obtained.  Particular  care 
should  be  exercised  in  excising  a  nsevus  of  the  eyelid  and  in  grafting 
the  defect.  If  the  nand  are  very  widely  distributed,  excision  should 
be  limited  to  those  upon  the  face  or  upon  areas  uncovered  by  clothing. 

The  development  of  nodular  growths  upon  a  ntevus  is  the  second 
indication  for  operation.  Every  na'vus  is  potentially  a  malignant  tumor 
— a  melanoma.  If  the  development  of  nodules  or  rapid  growth  arouses 
suspicion  of  malignancy,  thorough  removal  should  not  be  delayed. 

Xanthomas. — The  growths  occurring  in  the  skin  known  as  xantho- 
mas or  xanthelasmas  consist  of  small,  sulphur-yellow  or  brown,  circum- 
scribed areas  (xanthoma  planum),  and  nodular  elevations  (xanthoma 
tuberosum).  They  occur  most  frequently  in  the  skin,  especially  upon 
the  eyelids,  but  also  in  other  parts.  They  are  also  found  upon  the 
mucous  membranes  of  the  respiratory  passages,  mouth,  and  esophagus. 
These  growths  are  often  multiple,  occasionally  congenital.  The  acquired 
forms  are  most  common  in  old  age. 

These  growths  contain  cell  nests  which  resemble  those  found  in  nsexi. 
They  differ  from  these,  however,  in  that  they  contain  a  granular,  yellow 
pigment  and  fat  droplets.  The  cells  containing  fat  droplets  resemble 
closely  those  found  in  proliferating  fatty  tissue  (Borst). 

Literature. — Aschenbach.  Ein  Fall  von  orbitalem  Melanosarkom.  Virchows 
Arch.,  Bd.  143,  1896,  p.  324. — Borst.  Die  Lehre  von  den  Geschwiilsten.  Wiesbaden, 
1902,  pp.  943  and  960. — Dohhertin.  Beitrag  zur  Kasuistik  der  Geschwiilste.  Zieglers 
Beitriige  zur  path.  Anat.,  Bd.  28,  1900,  p.  42; — Melanosarkom  des  Kleinhirnes  und  des 
Riickeninarks.  Ibid.,  p.  52. — Just.  Ueber  die  Verbreitung  der  melanot.  Geschwiilste 
iin  Lyniphgefilssystem.  I.-D.,  Strassburg,  1888. — Krompecher.  Der  Basalzellenkrcbs. 
Jena,  1903,  p.  100  (Na^vi). — Joh.  Kroner.  Ein  ausgedehnter  Fall  von  Papilloma 
neuropathicum.  I.-D.,  Wiirzburg,  1890. — Lanz.  Experim.  Beitrag  zur  Frage  der 
Uebertragbarkeit  melanot.  Geschwulste.  Kochers  Festschrift.  Wiesbaden,  1891. — 
Martens.  Ein  Beitrag  zur  Entwicklung  des  Melanosarkoms  der  Chorioidea  bei  ange- 
borener  Melanosis  sclerae.  Virchows  Arch.,  Bd.  138,  1894,  p.  111. — Putiata-Kery-ch- 
baumer.  Das  Sarkom  des  Auges.  Wiesbaden,  1900. — Ribbert.  Das  Melanosarkom. 
Zieglers  Beitr.  zur  path.  Anat.,  Bd.  21,  1897,  p.  471; — Geschwulstlehre.  Bonn,  1904. — • 
Soldan.  Ueber  die  Beziehungen  der  Pigmentnialor  zur  Neurofibromatose.  Arch.  f. 
klin.  Chir.,  Bd.  .'")9,  1899,  p.  261.— C//ma.  Die  Ilistopathologie  der  Haut.,  1894;— Naevi 
und  Nacvokarzinome.  Bnrl.  klin.  Wochonschr.,  1893. — Wagner.  19  Falle  von  Melano- 
sarkom. Mimch.  mod.  AVochenschr.,  1887,  p.  14. — Wiener.  Ueber  ein  Melanosarkom 
des  Rektums  und  die  mehmot.  Geschwiilste  im  allgemeinen.  Zieglers  Beitr.  zur  path. 
Anat.,  Bd.  25,  1899,  p.  322. — Williams.  Beitriige  zur  Histologic  und  Ilistogenese  des 
Utcrussarkoms.     Zeitschr.  f.  Heilk.,  Bd.  15,  1894,  p.  141. 


LEIOMYOMAS 


887 


B.     TUMORS   COMPOSED   OF    MUSCLE 

Tumors  composed  mostly  of  muscle  fibers  are  called  myomas.  '  A 
leiomyoma  composed  of  smooth  muscle  filxn-s  is  dit'l'iTciit  iatcd  from  a 
rhahdomiioma  composed  of  striated   muscle  tiliei'S. 

CIIAPTEU    I 

Li:iOMYOMAS 


The  leiomyoma  is  an  especially  benign  tumor.  It  is  encapsulated 
and  rarely  has  an  infiltrating  growth  or  forms  metastases.  They  occur 
as  round  tumors  with  a  smooth  or  nodular  surface,  most  frequently  in 
the  uterus,  less  often  in  the 
muscular  layers  of  the  alimen- 
tary canal  and  urinary  tract. 
The  tumors  occurring  in  the 
uterus  (which  are  frequently 
nudtiple)  and  in  the  intestine 
grow  slowly  and  may  become 
as  large  as  a  man 's  head.  Up- 
on section,  they  have  a  gray- 
ish-red color,  and  the  irreg- 
ular, thick  network  of  wavy 
tissue  bundles  is  even  more 
pronoiniced  than  in  fibromas. 

Histology.  —  Upon  histo- 
logical examination,  longitu- 
dinal, oblique,  and  transverse 
bundles  of  smooth  muscle 
libers  with  rodlike  nuclei 
may  be  seen.  The  muscle  fibers  have  blunt,  rounded  ends  and  may  be 
easily  differentiated  from  the  pointed  connective-tissue  fibers  found  in 
fibronuis.  Between  the  bundles  of  muscle  fibers  lie  varying  amounts 
of  fibrous  tissue  which  carries  the  blood  vessels.  The  fibrous  tissue  may 
encircle  the  bundles  of  smooth  muscle  fibers  or  run  parallel  with  them. 
The  tumor  is  either  surrounded  by  a  thin  capsule,  being  sharply  de- 
limited from  the  surrounding  tissues,  or  bundles  of  muscle  fibers  extend 
into  the  surrounding  tissues,  and  then  the  tumor  is  firmly  attached. 

Consistency. — If    there    is    but    little    fibrous    tissue,    the    tumor    is 
soft   and  succulent;   if,  however,   it   is   well  developed,  the   tumor  has 


.  3S,'>. — Lkidmyoma  of  tiik  I'tiohi-s.    o,  Tr;ui> 
verse  section  of  bundle  of  imisele  libers. 


DIFFERENT   VARIETIES  OF   TUMORS 


the  consistency  of  a  fibroma  (fibromyoma).  A  large  nnmber  of  di- 
lated vessels  may  also  be  present,  and  the  tumor  is  then  called  a 
fihromyoma  telearigiectaticum.  Malignant  myomas  are  very  cellular. 
They  resemble  spindle-cell  sarcomas,  as  they  grow  rapidly,  infiltrate 
surrounding  tissues,  and  may  form  metastases.  It  cannot  be  posi- 
tively determined  in  these  malignant  myomas  whether  the  sarcoma  de- 
velops from  the  fibrous  tissues  of  the  tumor  or  from  the  muscle  fibers 
proper. 

Regressive  Changes. — In  the  large  tumors  all  the  regressive  changes 
may  be  fcmnd  which  follow  an  insufficient  blood  supply.  Large  cavities 
filled  with  detritus,  areas  that  have  undergone  hyaline  degeneration  or 
have  become  calcified,  and  in  pedunculated  myomas  an  anlematous  infil- 
tration, the  result  of 
venous  stasis  following 
torsion  or  kinking  of 
the  pedicle,  may  be 
seen. 

Origin  of  Leiomyo- 
mas.— Nothing  but  con- 
jectures, based  upon 
the  occasional  finding 
of  glandular  elements 
in  myomas  of  the  ute- 
rus and  intestinal  wall, 
can  be  made  concern- 
ing the  genesis  of  leio- 
myomas. Apparently 
all  myomas,  certainly 
the  adenomyomas  con- 
taining epithelial  tu- 
bules, are  the  result  of 
developmental  disturb- 
ances. Pieces  of  mus- 
cle become  separated 
from  their  nornuil  con- 
nections early  in  em- 
bryonal life,  Avhich  assume  nii  iudt^piMidcMit  growth  and  form  tumors 
later  (Ribbert). 

Most  Common  Sites  for  Development.— Leiomyomas  are  most  common 
in  tlie  uterus.  A  large  number  may  develop  in  the  fundus,  being  pres- 
ent in  early  life  as  small  growths.  They  may  be  situated  beneath  the 
iiiiicoiis  or  serous  iiiembi'aiie  (suhmueoiis  oi-  subserous  fibromyomas)  or 
ill    <li<'    utcritie    wall     ( iiiti'amui'al    (ihroiinomas ) .      Tlu'    submucous    and 


Fig.  387. — Utehus  with  Subserous  Myoma  Removed 
FijoM  A  Patient  Thirty-nine  Years  of  Age,  Frontal 
Section. 


LEIOMYOMAS 


889 


subserous  foi-ins  .-ii-c  fi-0(|n('ntly  podimciilated.  They  form  round  or 
heniisi)lK'i'ie;U  eiic.ip.suhited  tuiiiors  of  tinner  consistency  than  the  uterine 
musculature,  and  cause  a  number  of  ditVerent  synii)toms  (severe  menor- 
rhagia  or  metrorrhagia  being  the  most  prominent).     Fibromyomas  of 


^t 


Fig.  388. — Fibromyoma  of  the  Posterior  Wall  of  the  Rectum  Removed  by  Resection 
OF  the  Rectum  (Male  Patient  Thirty'-fivk  Years  of  Age).      (Lexer.) 


the  uterus  interfere  with  pregnane)^  and  labor,  and  mny  also  becon)e 
infected  and  undergo  putrefactive  changes.  The  ligaments  and  tubes 
are  most  frequently  involved  after  the  uterus. 

Adenomyo7}ias. — It  is  important  in  discussing  the  genesis  of  myomas 
of  the  uterus  to  note  that  von  Kecklinghausen  lias  demonstrated  tubules 
and  cavities  lined  with  cubical,  cylindrical,  and  ciliated  epithelium 
within  the  tumor  tissue  in  some  eases.  These  adenomyomas  are  usually 
small,  poorly  defined,  subserous  tumors,  occurring  most  frecpiently  upon 
the  posterior  surface  of  the  uterus  at  the  junction  of  the  tubes  with  the 
uterus,  in  the  broad  and  round  ligaments.  It  is  supposed  that  some 
of  these  tumors  develop  from  displaced  nuicous  glands,  some  from  the 
Wolffian  body  or  duct,  and  some  from  IMiiller's  duct,  pieces  of  muscle 
being  displaced  with  the  epithelium. 
57 


ggO  DIFFERENT   VARIETIES  OF  TUMORS 

Leiomyomas  of  the  Inlestines,  (EsopJidgus,  J-riuary  Passages,  etc.— 
Leiomyomas  are  found  less  ft-eciueiitly  iu  the  gastrointestinal  tract,  de- 
veloping from  the  musenlatnre. 

Myomas  developing  in  different  parts  of  the  esophagus  usually 
remain  small  and  cause  no  symptoms.  ]\Iyomas  of  the  stomach,  of  the 
small  and  large  intestine  and  rectum  grow  slowly.  They  may  become 
as  large  as  a  man's  head.  These  tumors  may  be  sessile  or  pedunculated. 
Sometimes  they  grow  into  the  lumen  of  the  bowel,  while  at  other  times 
they  develop  upon  the  outer  side.     They  may  give  rise  to  a  number  of 


Fig.  389. — MALiG>fANT  Leiomyoma  of  the  Bladder.  (Maie  patient,  sixty  years  of  age.) 
The  sub.serous  myoma  which  was  attached  to  tlie  bladder  wall  by  a  broad  base  had 
developed  into  the  abdominal  cavity.  It  was  necessary  to  resect  the  wall  of  the  bladder 
during  the  removal  of  the  ttimor.  No  recurrence  after  four  years.  (Lexer.)  Dotted 
line  indicates  the  outline  of  the  bladder. 

different  symi)toms  (intestinal  ol)stru<'tion,  intussusception,  ha'morrhage 
after  ulceration  of  the  mucous  membrane).  ''J'he  finding  of  pancreas 
tissue  in  a  myoma  of  the  stomach  (Cohen)  indicates  that  these  tumors, 
like  adeiiomyomas  of  the  uterus,  develoj)  fi'om  a  congenital  anlage.  Ma- 
lignant myomas  are  very  rare. 

Myomas  of  the  urinary  tract  are  not  very  common.     Up  to  the  pres- 


LEIOMYOMAS  891 

ent  time  only  seventeen  cases  have  been  described.  They  develop  from 
the  musculature  and  may  prow  into  the  cavity  of  the  bladder  or  exter- 
nally (Fig.  389),  attaining  considerable  size.  Biittner  found  a  large 
myoma  in  the  urethra.  Small  myomas  which  were  attached  to  the 
fibrous  capsule  have  been  found  in  the  kidneys. 

Pure  myomas  are  rarely  foimd  in  the  prostate.  Usually  a  part  or  all 
of  the  gland  becomes  hypertrophied,  all  of  the  elements  being  involved. 

IMyomas  occasionally  occur  in  the  mammary  glands  and  testicle.  Myo- 
mas of  the  skin  occur  upon  the  trunk  and  extremities.  They  appear  as 
small  multiple  nodules  of  firm  consistency  which  project  above  the  surface. 
These  tumors,  covered  by  normal  skin,  never  become  larger  than  a  hazel- 
nut. They  frequently  give  rise  to  severe  pain.  They  develop  from  the 
musculature  of  the  cutaneous  blood  vessels  or  hair  follicles.  Clinically 
they  cannot  l)e  differentiated  from  fil)romas  of  the  cutaneous  nerves. 

Diagnosis. — The  diagnosis  of  leiomyomas  occurring  in  the  uterus  is 
easily  made.  Leiomyomas  developing  in  other  organs  are  so  rare  that  if 
a  slowly  growing  tumor  is  found,  the  diagnosis  of  a  fibroma,  or,  if  rapidly 
growing,  of  a  sarcoma  is  usually  made.  Only  when  it  can  be  demon- 
strated that  a  large  round  abdominal  tumor  is  connected  with  the  stom- 
ach, intestinal,  or  bladder  wall,  should  a  myoma  be  thought  of.  ]\Iyomas 
of  the  skin  may  easily  be  mistaken  for  fibromas,  as  they  are  so  painful. 
In  these  cases  a  myoma  should  be  thought  of  if  the  changes  so  fre- 
quently associated  with  fibromas  of  the  nerves  (pigmented  nsevi  and 
soft  warts)  are  wanting. 

Treatment. — An  attempt  should  be  made  in  the  treatment  to  remove 
the  tumor  completely.  If  the  tumors  are  scattered  throughout  the 
uterus,  a  hysterectomy  should  be  performed.  Encapsulated  tumors 
may  be  enucleated.  If  the  tumor  is  not  encapsulated  the  dissection 
should  be  free,  removing  the  muscle  from  which  the  tumor  develops. 

RHABDOMYOMAS 

The  rhabdomyomas  are  rare  tumors  which  are  composed  of  striated 
muscle  fibers  and  a  vascular  intercellular  connective  tissue.  Sometimes 
these  tumors  are  benign,  sometimes  malignant.  If  other  varieties  of 
tissue  are  found  in  the  growth  they  are  classified  as  mixed  tumors. 

Gross  Appearance  and  Histology. — Macroscopically  they  appear  as 
nodular,  usually  well-defined,  growths  of  varying  consistency.  They 
may  attain  considerable  size.  The  interlacing  of  the  fibers  cannot  be  so 
easily  seen  in  the  grayish-red  or  gray  tissue  as  in  leiomyomas. 

Microscopically  no  completely  developed  striated  muscle  fibers  are 
found,  but  embryonal  types  of  cells  and  fibers  in  difi'erent  stages  of  de- 
velopment.   The  latter  appear  as  hollow,  tubular,  or  solid,  multinucleated 


892  DIFFERENT   VARIETIES  OF   TUMORS 

bands  of  considerable  length  and  different  thicknesses  in  which  both  the 
transverse  and  longitudinal  striations  may  be  distinctly  seen.  The  cellu- 
lar forms  contain  spindle  cells  with  long  threadlike  processes,  parts  of 
which  have  transverse  striations,  and  irregular  round  or  oval  cells,  often 
of  considerable  size,  Avith  one  or  many  nuclei.  All  of  these  forms  of 
cells  fre(iuently  contain  glycogen  (Marchand),  which  may  be  distinctly 
seen,  upon  the  addition  of  tincture  of  iodin,  as  large  brown  globules. 
On  the  fibers  with  transverse  striation  there  may  be  indications  of  a 
poorly  developed  sarcolemma. 

The  structure  of  different  rhabdomyomas  differs,  as  in  some  cases 
the  round  or  spindle  cells  predominate,  in  other  cases  the  muscle  fibers. 
The  more  the  cells  and  fibers  are  grouped  and  interlaced,  the  more  these 
tumors  resemble  histologically  leiomyomas  and  fibromas. 

Origin  of  Rhabdomyonias. — In  discussing  the  origin  of  rhabdomyo- 
mas it  is  important  to  note  that  many  mixed  tumors,  M^hich  undoubtedly 


t 


m. 


% 


Fig.  390. — Rhabdomyoma  or  the  Temporal  Region,  h,  b,  Muscle  cells  cut  parallel  to  their 
long  axes  in  which  fusiform  enlargements  and  transverse  striations  may  be  seen,  g,  gr, 
Roimd  cells  with  processes;  h,  round  cell  without  processes.  The  dark  deposits  repre- 
sent drops  of  glycogen.      (From  Ribbcrt.) 

are  the  result  of  developmental  disturbances,  contain  striated  muscle 
fibers,  and  that  only  the  embryonal  forms  of  these  fibers  are  found  in 
pure  myomas.  Rhabdomyomas  are  of  congenital  origin  or  develop  in 
early  life,  and  as  they  occur  in  organs  which  do  not  contain  striated 
fibers,  one  seems  justified  in  concluding  that  thi>se  tumors  develop  from 
gei'iiiiiial  iiiu.scle  tissue  which  was  separated  from  normal  physiological 
connections  and  displaced  during  eml)ryonal  life  (Ribbert).  It  has 
also  l)een  suggested  that  the  smooth  muscle  fibers  composing  a  leio- 
myoma Ix'come  transformed  into  striated  fibers,  thus  forming  a  rhabdo- 
myoma, and  that  normal,  fully  developed  muscle  miglit  proliferate  to 
form  this  type  of  tumor.  There  are  a  number  of  objections  which  may 
be  raised  against  both  of  these  suggestions  (Borst  and  Ribbert). 


LEIOMYOMAS  893 

Most  Common  Sites  for  Development.— Kliabdomyomas  occur  most 
frequently  in  the  kidney,  which  is  gradually  destroyed  as  the  tumor 
enlar<;es,  so  that  finally  a  few  remnants  only  are  left.  The  tumor  may 
reach  the  size  of  a  child's  head  and  send  out  nodular  and  polypoid 
processes  into  the  pelvis  of  the  kidney.  Occasionally  rhabdomyomas 
appear  as  polypoid  tumors  in  the  pelvis  of  the  kidney,  in  the  bladder, 
and  as  nodular  growths  in  the  testicles.  Of  the  other  organs  the  uterus 
and  heart  are  the  most  important  sites  for  the  development  of  these 
tumors.  Rhabdomyomas  of  the  uterus  appear  as  polypoid  growths  pro- 
jecting into  the  vagina.  They  occur  in  the  heart  as  congenital,  multiple, 
usually  small  grayish-red  nodules.  Single  tumors  have  been  described 
in  a  number  of  different  parts — in  the  oesophagus,  stomach,  parotid 
gland,  pro.state,  in  the  muscles  of  the  extremities,  and  about  the  but- 
tocks and  hips,  in  the  tongue,  orbit,  temporal  regions,  etc. 

Mode  of  Growth. — According  to  Ribbert,  these  tumors  enlarge  as  the 
result  of  the  proliferation  of  the  young  spindle  and  round  cells,  which 
later  become  transformed  into  striated  muscle  fibers.  The  growth  is 
frequently  expansive  and  slow,  but  it  may  be  infiltrating  in  character. 
Then  the  tumor  enlarges  rapidly,  the  surrounding  structures  are  in- 
vaded and  metastases  form.  It  is  not  known  in  these  cases  whether 
the  tumor  is  to  be  regarded  as  a  pure  malignant  rhabdomyoma  or  as  a 
fibrosarcoma  containing  striated  muscle  fibers.  The  latter  is  frequently 
the  ease  in  mixed  tumors,  but  it  should  not  be  forgotten  that  the  young, 
non-striated,  muscular  elements  may  be  easily  mistaken  for  sarcoma  cells. 

Diagnosis.— The  clinical  peculiarities  of  these  tumors  are  not  suf- 
ficiently marked  to  enable  one  to  make  a  po.sitive  diagnosis.  The  diag- 
nosis is  limited  to  determining  whether  the  growth  is  benign  or  malig- 
nant, and  then,  depending  upon  the  form,  position,  and  rapidity  of 
growth  of  the  tumor,  one  can  make  a  tentative  diagnosis  of  a  fibroma 
or  of  sarcoma,  or,  if  it  occurs  in  the  genital  tract,  of  a  mixed  tumor. 

The  operation  which  should  be  performed  depends  upon  the  extent, 
position,  and  character  of  the  tumor. 

Literature. — Becker.  Bcitrag  zur  Kenntnis  der  wahren  Muskelgeschwiilste  des 
Hodens.  Virchows  Arch.,  Bd.  163,  1901,  p.  24-i.—BiiUner.  Ein  Fall  von  Myom  der 
weiblichen  Urethra.  Zeitschr.  f.  Gebiirtshilfe,  Bd.  28,  1894,  p.  136.— Cohen.  Beitrage 
zur  Hi.s;tologie  und  Histogenese  der  Myome  des  Uterus  und  des  Magens.  Ibid.,  Bd. 
158,  1899,  p.  524. — Fujinama.  Ein  Rhabdomyosarkom  mit  hyaliner  Degeneration 
(Zylindrom)  im  willkiirlichen  Muskel.  Jhid.,  Bd.  160,  1900,  p.  20)?,.— Hess.  Ein  Fall 
von  multiplen  Dermatomyomen  an  der  Nase.  Ibid.,  Bd.  120.  1890,  p.  321. — Lexer. 
Myome  des  Mastdarmes.  Arch.  f.  klin.  Chir.,  Bd.  68,  1902,  S.  241; — Myosarkom 
der  Blase.  Zentralbl.  f.  Chir.,  1904.  p.  22.—Marchnnd.  Ueber  einen  Fall  von  Myo- 
sarcoma striocellulare  der  Niere.  Virchows  Arch.,  Bd.  73,  1878,  p.  289: — Ueber  eine 
Geschwulst  aus  quergestreiften  Muskelfasern  mit  ungewohnlichem  Gehalt  an  Glj^kogen. 


894  DIFFERENT    VARIETIES   OF   TUMORS 

C.     TUMORS   COMPOSED    OP    NERVE    ELEMENTS 
CHAPTER   I 

NEUROMAS 

FiBROMAS,  myxomas,  and  sarcomas  of  nerves,  which  have  also  been 
called  false  neuromas,  should  not  be  classified  with  this  group  of  tumors. 
Only  those  tumors  composed  of  nervous  elements  belong  here.  They 
are  exceedingly  rare,  developing  apparently  only  from  the  sympathetic 
nerves  upon  which  they  appear  as  round  or  nodular  growths  resembling 
fibromas.  Sometimes  they  attain  considerable  size,  becoming  as  large  as 
a  man's  head. 

Histology. — They  are  composed  of  interlacing  bundles  of  nerve 
fibers,  the  majority  of  which  are  non-medullated,  the  smaller  part 
medullated.  Between  these  fibers  are  found  varying  numbers  of  gan- 
glion cells,  which  sometimes  appear  as  poorly  developed,  round  cells, 
at  other  times  they  give  oft'  axis  cylinders.  Neurilemma,  interfibrillar 
connective  tissue,  and  a  few  vessels  are  also  found  in  these  tumors.  The 
terms  ganglio-neuroma  or  neuroma  ganglio-cellulare  have  been  applied 
to  these  tumors,  indicating  that  they  contain  both  nerve  fibers  and  gan- 
glion cells. 

The  few  cases  (Knauss,  M.  B.  Schmidt,  Beneke,  and  Kredel)  that 
have  been  observed  have  occurred  mostly  in  small  children.  They 
appear  as  large  tumors  developing  in  the  place  of  or  near  the  sym- 
pathetic ganglia,  or  as  small,  multiple  tumors  of  the  skin  developing 
supposedly  from  the  sympathetic  nerves,  which  contain  a  few  ganglion 
cells,  supplying  the  blood  vessels  (Knauss).  The  retroperitoneal  tumor 
described  by  Beneke  was  benign,  and  caused  symptoms  only  by  its  posi- 
tion and  size. 

Symptoms,  Diagnosis,  and  Treatment. — The  clinical  peculiarities  of 
these  tumors  are  not  striking  enough  to  enable  one  to  make  a  positive 
diagnosis. 

Nothing  definite  is  known  concerning  the  origin  of  ganglio-neuromas. 
Their  early,  even  congenital,  occurrence  and  the  presence  of  incom- 
pletely developed  nervous  elements  indicate  that  they  are  the  result  of 
some  disturbance  in  the  develofjiuent  of  the  sympathetic  nervous  system 
(Ribbert,  Borst). 

Surgical  tic.itment  should  be  instituted  when  these  tumors  are 
accessible. 


GLIOMAS  895 

Amputation  Neuromas. — The  small  nodular  thickenings  which  de- 
velop upon  injured  nerves  are  called  traumatic  neuromas,  although  they 
are  not  true  tumors,  strictly  speaking. 

They  are  found  especially  upon  the  nerves  in  amputation  stumps 
(so-called  amputation  neuromas),  upon  the  central  end  of  completely 
divided  nerves  or  the  sides  of  incompletely  divided  ones.  They  develop 
as  the  result  of  mechanical  irritation  of  the  nerves  which  lie  immediately 
beneath  the  skin,  that  become  caught  in  a  scar  or  lie  upon  the  edge  of 
a  bone  (e.  g.,  ahmg  the  jaw  and  supraorbital  ridge  after  saber  cuts). 
There  is  a  proliferation  of  the  connective  tissues  of  the  nerve  and  a 
regeneration  of  medullated  and  non-medullated  nerve  fibers,  which  grow 
out  for  a  short  distance  and  then  bend  back  to  interlace  with  other 
])roliferating  fibers.  The  nodules,  which  form,  never  exceed  in  size  twice 
the  diameter  of  the  nerve  involved,  and  merely  represent  an  excessive 
regenerative  growth  of  the  injured  nerve. 

Diagnosis  and  Treatment. — The  diagnosis  can  be  easily  made.  Small, 
hard  nodules,  which  are  painful  upon  pressure,  lie  beneath  the  skin  in 
connection  with  the  scar  or  immediately  adjacent  to  it. 

They  may  be  easily  removed.  Precaution  should  be  taken  against 
their  development  when  amputations  are  performed.  The  nerves  to 
be  divided  should  be  drawn  out  from  the  wound  and  cut  short  so  that 
they  may  retract  some  distance  beyond  the  cut  surfaces. 

Literature. — Beneke.  Ueber  gangliose  Neurome.  Zieglers  Beitrage  zur  path. 
Anatomie,  Bd.  30,  1901,  p.  1. — Benckc  unci  Kredcl.  Ueber  Ganglionneurome  und  andere 
Geschwlilste  des  peripheren  Nervensy stems.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  67,  1902, 
p.  239. — Busse.  Ein  grosses  Neuroma  gangliocellulare  des  Nervus  sympathicus.  Vir- 
chows  Archiv,  Bd.  151,  1898,  p.  66  of  the  Supplement. — Goldmann.  Beitrag  zur  Lehre 
von  den  Neuromen.  Beitr.  z.  klin.  Chir.,  Bd.  10,  1893,  p.  13. — Knauss.  Zur  Kenntnis 
der  echten  Neurome.  Virchows  Arch.,  Bd.  153,  1898,  p.  29. — M.  B.  Schmidt.  Ueber 
ein  ganglienzellenhaltiges  wahres  Neurom  des  Sympathikus.  Virchows  Archiv,  Bd. 
155,  1899,  p.  557. 


CHAPTER    II 

GLIOMAS 

Tumors  developing  from  neuroglia,  the  stroma  of  the  central  nervous 
system,  are  called  gliomas.  They  are  composed  of  glia  cells  varying  in 
their  degree  of  development.  They  occur  in  the  brain,  spinal  cord,  and 
the  eye,  the  last  having  histological  peculiarities. 

Peculiarities  of  Gliomas. — Gliomas  of  the  brain  occur  as  tumors,  vary- 
ing in  size  from  a  cherry  to  a  fist,  within  the  white  and  gray  substance. 


896  DIFFERENT   VARIETIES   OF   TUMORS 

At  times  they  infiltrate  an  entii'e  hemisphere,  the  tumor  gradually  fusing 
with  the  surrounding  tissues.  It  is  frecjuently  impossible  to  determine 
the  boundaries  of  the  tumor,  as  it  may  be  of  about  the  same  color  and 
consistency  as  the  surrounding  nervous  tissue.  Frecpiently  such  a  tumor 
can  be  recognized  niacroscopically  by  the  flattening  of  the  convolutions 
covering  it,  or  upon  section  by  small,  scattered,  hicmorrhagic  foci,  ne- 
crotic areas  or  cavities  resulting  from  softening  and  liquefaction.  Gli- 
omas occur  most  frequently  in  early  childhood.  Sometimes  they  appear 
as  multiple,  small,  hard  nodules  upon  the  inner  surface  of  the  ventricle. 
They  usually  grow  very  slowly.  The  cellular  forms  grow  rapidly,  infil- 
trate and  destroy  the  surrounding  tissues;  only  rarely  are  the  latter 
displaced  by  the  growth.  Gliomas  do  not  develop  above  the  surface  of 
the  brain. 
,  Symptoms. — The  symptoms  are  those  of  a  brain  tumor,  and  depend 
upon  the  position  of  the  growth  and  the  increase  in  intracranial  pres- 
sure. Large  haemorrhages  into  the  tumor  are  connnon,  and  apoplecti- 
form seizures  are  frequent. 

Varieties. — Gliomas  of  the  Spinal  Cord. — Gliomas  of  the  spinal  cord 
are  most  common  in  childhood.  They  frequently  surround  the  central 
canal.  They  grow  slowly,  forming  long,  conelike  growths,  or  transform 
a  considerable  extent  of  the  cord  into  a  gray  mass,  so  that  upon  section 
only  a  narrow  peripheral  layer  of  normal  tissue  can  be  seen.  Occa-' 
sionally  the  growth  extends  through  this  jDcripheral  layer  and  reaches 
the  pia  mater  (Pels-Leusden).  Cyst  formation  is  frequent  in  gliomas 
of  the  cord.  This  is  partly  the  result  of  dilatation  of  the  central  canal, 
and  partly  of  softening  of  the  tumor  tissue.  The  symptoms  are  those 
of  a  spinal  tumor.  When  cyst  formation  is  marked,  the  symptoms  may 
resemble  those  of  syringomyelia. 

The  progyiosis  of  gliomas  of  the  brain  and  spinal  cord  depends  upon 
their  position.  They  have  an  infiltrating  growth,  and  are  therefore 
closely  related  to  malignant  growths,  although  they  grow  slowly  and 
seldom  form  metastases. 

Gliomas  of  the  Eye. — Gliomas  of  the  eye  develop  from  the  retina. 
They  appear  as  nodular  gray  and  white  tumors,  and  grow  into  the  vitre- 
ous humor.  They  grow  rapidly,  extending  through  the  cornea  exter- 
nally, through  the  sclera  into  the  orbit,  or  pass  along  the  optic  nerve  to 
the  cranial  cavity.  These  tumors  occur  in  children,  not  infrequently 
being  bilateral.  Some  are  of  congenital  origin.  They  destroy  the  eye 
affected,  and  frequently  recur  after  enucleation  of  the  eye.  They  are 
as  iiijiligiiant  as  sarcomas. 

Histology. — Histologically,  gliomas  of  the  brain  and  spinal  cord  are 
composed  of  glia  cells  and  a  thick  network  of  interlacing  fibrilhe,  part 
of  which  are  the  processes  of  the  glia  cells.     The  fewer  the  cells  in 


GLIOMAS  897 

proportion  to  the  mnnber  oi'  (ihi-illu',  the  liarder  the  tiiinor.  The  num- 
ber of  blood  vessels  in  these  ^L^rowths  varies.  Small  or  larye,  round  or 
slitlike  cavities  lined  with  columnar  cells  are  occasionally  found.  The 
latter  are  derivatives  of  the  ependymal  epithelium  from  which  the  glia 
cells  develop.  If  proliferating  ganglion  and  nerve  cells  are  also  i)resent, 
the  tumor  is  called  a  neuroglioma  ganglioiiare  (Ziegler).  If  most  of 
the  cells  are  fusiform  in  shape  and  the  fibrilke  are  not  very  i^ronGunced, 
the  tumor  might  easily  be  mistaken  for  a  sarcoma. 

Gliomas  of  the  eye  contain  large  numbers  of  round  or  oval  cells 
with  processes,  and  only  occasionally  an  intercellular  fibrillar  substance. 
They  also  frequently  contain  cylindrical  cells,  radially  arranged  to  form 
a  lumen  producing  rosctteVihe  formations.  It  has  been  suggested  that 
these  tumors  develop  from  the  neuroepithelium  of  the  external  layer 
of  the  retina  (therefore  they  are  called  neuroepitheliomas  by  Winter- 
steiner). 

Origin  of  Gliomas. — l*ro])ably  all  gliomas  nnist  be  regarded  as  the 
result  of  some  disturbances  in  embryological  development  of  the  brain, 
spinal  cord,  or  eye.  Congenital  occurrence,  development  in  early  age, 
association  with  malformation  of  the  brain  and  spinal  cord,  the  bilateral 
occurrence  of  glioma  of  the  eye,  and  their  development  in  many  mem- 
bers of  the  same  family  support  this  theory  (Ribbert). 

Diagnosis  and  Treatment. — A  positive  diagnosis  of  a  glioma  can  be 
made  when  both  eyes  are  affected.  In  other  cases  a  glioma  may  be 
easily  confused  with  a  sarcoma.  Usually  one  must  be  content  in  making 
a  diagnosis  of  a  tumor  without  being  more  specific. 

Treatment  is  successful  only  in  gliomas  of  the  eye,  and  in  these 
cases  the  contents  of  the  orbit  should  be  removed  early.  Gliomas  of  the 
brain  and  spinal  cord  are  very  frequently  so  situated,  or  are  so  exten- 
sive that  complete  removal  is  impossible. 

Literature. — L.  Bruns.  Gehirntumoren.  Enzykloj).  Jahrb.  von  Eulenburg,  Bd. 
5,  1895,  p.  159. — Greeff.  Gliom.  in  Orths  Lehrb.  tier  path.  Anat.  Path,  des  Auges, 
p.  400. — Pels-Leusden.  Ueber  einen  eigentiimlichen  Fall  von  Gliom  des  Riickeninarkcs 
mit  Uebergreifen  auf  die  weichen  Hiiute  des  Riickenmarkes  und  Gehirns.  Zieglers 
Beitr.  zur  path.  Anat.,  Bd.  23,  1898,  p.  69. — Snxer.  Ueber  Syringoinyelie.  Zusainnion- 
fassendes  Reterat  iiber  die  seit  1892  erschienenen  Arbeiten.  Zentralbl.  fiir  allg.  I'ath. 
u.  path.  Anat.,  Bd.  9,  1898,  pp.  6  and  49; — Ependymepithel,  Gliome  und  epitheliale 
Geschwiilste  des  Zentralnervensystems.  Zieglers  Beitr.  zur  path.  Anat.,  Bd.  32,  1902, 
p.  276. — Strobe.  Ueber  Entstehung  und  Bau  der  Gehirngliome.  Ibid.,  Bd.  18,  1895, 
p.  405. — Winter steiner.     Ueber  das  Neuroei)ithelioma  retinae.     Leipzig-Wien,  1897. 


898  DIFFERENT    VARIETIES   OF   TUMORS 


D.     TUMORS   DEVELOPING   FROM    EPITHELIUM 
CHAPTER    I 

FIBROEPITHELIAL   TUMORS 

In  fibroepithelial  growths  there  is  a  proliferation  of  both  the  epi- 
thelium and  connective  tissue,  although  they  may  vary  in  their  degree 
of  development,  while  in  carcinomas  the  connective  tissues  play  a  subor- 
dinate role,  forming  merely  the  framework  of  the  tumor  which  supports 
the  cells  and  blood  vessels. 

'The  structural  relationship  between  epithelium  and  connective  tis- 
sue in  fibroepithelial  tumors  finds  its  prototype  in  normal  tissue.  In  the 
group  of  papillomas  the  same  relation  exists  between  epithelium  and 
connective  tissue  as  in  the  skin  and  mucous  membranes.  The  structure 
of  an  adenoma  resembles  that  of  a  gland,  and  the  structure  of  epithelial 
cysts  resembles  in  a  number  of  ways  the  structure  of  skin  and  mucous 
membrane. 

(a)  PAPILLOMAS 

Papillomas  occur  upon  the  free  surface  of  the  skin  and  mucous  mem- 
branes. They  are  usually  small  tumors,  rarely  becoming  larger  than  a 
walnut  or  hen's  egg,  have  an  expansive  growth,  and  result  from  a  hyper- 
plasia of  the  epithelium  with  a  corresponding  new  growth  of  the  con- 
nective tissue  and  blood  vessels.  Long,  branched  papilla^,  covered  from 
summit  to  base  with  epithelial  masses,  extend  down  into  the  connective- 
tissue  framework  of  the  tumors.  If  the  papilljE  are  surrounded  by 
connective  tissue  and  are  held  together,  the  new  growth  resembles  a 
round  nodule  or  a  wart.  If  the  papillfe  and  their  branches  are  sepa- 
rated, deep-.fissured,  blackberry-,  grape-,  and  villouslike  tumors  are 
formed  which  may  be  attached  to  the  skin  or  mucous  membrane  by  a 
brojid  base  or  thin  pedicle.  Marked  cornification  of  the  epithelium  pro- 
duces another  variety  of  papilloma  of  the  skin.  In  benign  tumors  the 
l)roliferati()n  never  extends  below  the  subepithelial  tissues. 

Clinical  Appearance. — Papillomas  appear  as  single  or  multiple  tu- 
mors, often  being  closely  grouped,  Avith  broad  bases  or  short  pedicles. 
As  a  rule,  they  grow  slowly.  Sometimes  they  bleed  profusely  after 
injuries  in  wliieh  the  ])ase  or-  pedicle  is  torn.  After  incomplete  removal 
(ligation  of  pedicle,  cauterization  with  weak  caustics),  they  may  begin 
to  enlarge  and  grow  rapidly.  Usually,  after  growing  slowly  for  some 
time,  they  remain  stationary. 


FIBROEPITHELIAL  TUMORS 


899 


Varieties. — rapHloinas  of  ilie  Skin. — The  epitholiuin  covering  papil- 
lomas of  the  skin  becomes  eornified.  They  are,  therefore,  harder  than 
papillomas  of  the  mucous  membranes.  These  tumors  develop  most  fre- 
(piently  upon  the  scalp  of  old  people,  but  they  also  occur  in  the  axil- 
lary fossa,  the  inguiucd  regions,  in  the  folds  below  the  breasts,  on  the 
l)ack  and  perineum,  about  the  anus,  and  upon  otlier  parts  of  the  body 
exposed  to  continual  irritation  by  sweat,  rubbing,  and  uncleanliness. 
p-—         -  -  About  the  temporal 

regions  they  may 
develop  from  sebor- 
rha?ic  patches  {vide 
p.  940). 


I     -'W^ 


Fig.  391. — Papilloma  of  the  Skin  which  has  been  Present 
FOR  Thirty  Years  (Man  Sixty-four  Years  of  Age). 


Fig.  392.  —  Section  of 
the  P.-\.pilloma  Rep- 
resented in  Fig.  391. 


Pointed  condylomas  develop  upon  the  external  genitalia  and  the 
adjacent  skin  following  irritation  produced  by  a  gonorrheal  discharge. 
In  form  and  structure  they  are  papillomas.  They  are  not,  however, 
tumors  strictly  speaking,  but  are  hyperplastic  growths,  developing 
upon  a  chronically  inflamed  area.  The}^  disappear  when  the  cause  is 
removed. 

PapilIo)iuis  of  Mucou.'i  Memhraucs. — Papillomas  of  the  S(juamous 
mucous  membranes  are  found  in  the  mouth  (lips,  cheek,  soft  palate,  and 
tongue),  often  developing  from  a  leukoplakia,  in  the  pharynx,  larynx, 
oesophagus,  and  vagina.  They  usually  develop  in  old  people.  Papil- 
lomas of  the  larynx,  however,  are  found  most  frequently  in  children 
and  young  people;  occasionally  they  are  congenital.  They  are  usually 
multiple,  are  characterized  by  rapid  growth,  and  recur  after  removal. 

The  mucous  membrane  of  the  bladder,  more  rarely  that  of  the  ure- 
ter and  pelvis  of  the  kidney,  may  be  the  seat  of  single  or  multiple  papil- 
lary tumors,  the  so-called  villous  polypi.     They  are  soft,  pedunculated 


900 


DIFFERENT   VARIETIES   OF   TUMORS 


K 


Fig.  393. — Section  fbom  the  Border  of  a  Fissured  Pap- 
illoma OF  THE  Skin. 


growths,  often  att;iining'  the  size  of  a  fist. 
They  bleed  easily  and  profusely.  lIi)on  eysto- 
scopie  examination  the  delicate,  algivlike,  float- 
ing villi  may  be  seen.  The  surface  of  these 
tumors  is  covered  by  a  stratified,  transitional 
epithelium.  Carcinomas  of  the  urinary  tract 
may  appear  in  similar  forms  (villous  carci- 
nomas) or  develop 
from  simple  papil- 
lomas. 

Papillary  growths 
upon  mucous  mem- 
branes covered  with 
columnar  epithelium 
are  rare,  and  are 
found  almost  only  in 
the  rectum.  Occa- 
sionally they  develop 


in  the  nose,  uterus,  stomach,  and  bil- 
iary passages.  They  are  most  com- 
mon in  old  people,  forming  soft,  vil- 
lous tumors  with  a  short  pedicle  or 
broad  base,  and  vary  in  size  from  a 
pea  to  a  hen's  egg  (villous  polypi, 
tumor  villosus).  Injury  by  fiscal 
masses  may  be  followed  by  profuse 
haemorrhages. 

Horny  Warts  and  Ciitaneovs 
Horns.  —  Excessive  eornification  of 
the  epithelium  may  lead  to  the  for- 
mation of  horny  warts  and  cuta- 
neous horns.  The  former  appear  as 
small,  usually  flat,  nodules  upon  the 
skin.  They  are  covered  by  a  hard, 
fissured,  horny  layer  of  epithelium 
which  holds  the  hypertrophied, 
threadlike  papillae  together.  Often 
the  surface  of  these  growths  is  fis- 
sured and  of  a  thorny  appearance, 
resembling  a  papilloma.  These 
gi'ovvths  are  found  in  both  young 
and  old  people,  occurring  most  fre- 


FiG.  394. — MuLTii'LK  Papillomas  of  tiik 
Larynx.  (After  P.  von  Bruns,  Hand- 
book of  Practical  Surgery.) 


FIBROEPITHELIAL  TUMORS 


901 


qiiently  upon  the  fingers.    They  often  disappear  spontaneously  or  after 
a  slight  iuHanunation  following  an  abrasion  of  the  surface. 

The  cutaneous  horn  (cornu  cutaneum)  is  most  common  in  old  people, 
and  develops  most  frequently  upon  the  hairy  scalp  and  face  (Figs.  396 


x«»S9Bfc, 


•M 


^m. 


■'_r'/>-'' 


Fig.  395. — ^'lLLOus  Polyp  of  the  Urinary  Bl.\dder.      Pedunculated  tumor  the  size  of  a 
fist,  in  a  man  sixty-five  years  of  age. 

to  398),  the  eyelids,  nose,  cheeks,  lips,  and  ears  being  most  commonly 
affected.  Occasionally  they  are  found  upon  the  trunk,  the  extremities, 
the   prepuce,    and    the    scrotum.      Multiple   cutaneous    horns    are   rare. 

The  new  growth  begins  as  a  small 
wartlike  nodule  \^^ou  tlio  skin,  the 


y 


'  J 

Fig.  396. — Cut.\xeovs  Hokn  on  the  Ear.         Fig.  397. — Cut.^.nkuus  IIukn  on  the  Nose. 

horny  layer  of  Avhich  proliferates  to  form  a  remarkable  growth.  The 
horns  appear  either  as  short,  broad,  conical  projections,  or  as  narrow  but 
long   (10  to  30  cm.),  clawlike,  crooked  or  twisted  horns,  the  surfaces 


902  DIFFERENT    VARIETIES   OF   TUMORS 

of  which  are  dark  brown  or  black  and  have  longitudinal  striations.  The 
skin  at  the  base  of  such  a  horn  is  somewhat  thickened  and  reddened. 
If  a  cutaneous  horn  is  divided  longitudinally,  the  hardest  mass  is  found 
externally,  and  a  soft,  friable  substance  in  the  interior.  Upon  micro- 
scopical examination  long,   tliin   papilla?  may  be  seen   extending  some 


Fig.  398. — Cutaneous  Horn  of  thk  Lip  as  seen  from  Without  and  Upon  Section. 


distance  into  the  thickened  epithelium.  Proliferation  of  the  papillary 
layer  may  be  absent  (Biitge).  Occasionally  a  cutaneous  horn  develops 
from  a  papilloma  or  an  atheroma. 

The  cutaneous  horn  always  develops  again  after  it  falls  off  spon- 
taneously, is  rubbed  off,  is  ligated  oft',  or  is  incompletely  removed. 

Papillomas  Occurring  in  the  Brain. — In  rare  cases  delicate,  soft 
papillomas  have  been  found  in  the  ventricles  of  the  brain.  Such  papil- 
lomas are  connected  with  either  the  ependyma  (Saxer)  or  the  choroid 
plexus  (Briichanow). 

Origin  of  Papillomas. — In  discussing  the  origin  of  papillomas,  it  is 
important  to  remember  that  they  are  fre<iuently  secondary  to  chronic 
inflammatory  conditions.  Ribbert  has  been  able  to  produce  them  experi- 
mentally by  frequently  injuring  the  same  part  of  a  rabbit's  lip.  Prob- 
ably some  papillomas  are  the  result  of  developmental  disturbances, 
especially  the  cutaneous  papillomas  and  those  tumors  of  the  mucous 
membranes  the  epithelium  of  which  does  not  correspond  to  the  sur- 
rounding epithelium  (the  rare  squamous-cell  papillomas  occurring  upon 
mucous  membranes  covered  with  columnar  epithelium). 

Haemorrhage  from  Papillomas  and  Symptoms. — Clinically,  the  great- 
est significance  attaches  to  the  ha'mori-hage,  which  in  the  soft  forms  of 
papillomas  may  follow  slight  injuries  and  be  very  profuse.  The  other 
symptoms  depend  upon  the  position  of  the  tumor.  Papillomas  of  the 
larynx  may  cause  dangerous  dyspnroa  and  threaten  life.  Cutaneous 
horns  and  large  papillomas  of  the  eyelids  and  lips  may  cause  ugly  and 
distressing  deformities  (ectropion  or  drooping  of  tlie  upper  eyelid). 
Rapid  enlargement,  associated  with  induration  of  the  base  of  the  papil- 
loma, indicates  the  beginning  of  a  carcinoma  which  not  infrequently 
d('Vf'l(>[)S  upon  snch  a.  gi-owth. 

Indications  for  Treatment.— The  indication  in  the  treatment  of  these 
growths  is  to  remove  the  growth,  together  with  the  tissue  from  which  it 


FIBROEPITHELIAL  TUMORS  903 

(lev(>lo})S.  In  siiial!  ]);i])ill()iii;is  ol'  tlic  skin  a  imniber  of  apjilicjitioiis  of 
fuming  nitric  acid  generally  suffices.  Similar  growths  on  accessible 
mucous  membranes  should  be  cut  away  with  scissors,  and  the  wound 
then  touched  with  the  thermocautery.  Large  tumors  and  those  with 
broad  bases  should  be  circumscribed  and  removed  together  with  the 
tissue  from  w^hich  they  spring.  In  the  removal  of  papillomas  of  the 
larynx  and  bladder  a  preliminary  operation  is  often  performed  when 
they  are  so  large  that  they  cannot  be  removed  by  intralaryngeal  and 
intravesical  instrumentation. 

Incomplete  removal  is  followed  by  rapid  recurrence,  and  possibly 
favors  the  development  of  a  carcinoma. 

Literature. — Bdtge.  Zur  Kasuistik  multipler  Keratosen.  Deutsche  Zeitschr.  f. 
Chir.,  Bd.  6,  1876,  p.  474. — Bruchcmow.  Ueber  einen  Fall  von  Papillom  des  Plexus 
chorioideus  ventriculi  lateralis  sin.  bei  einem  2^  jahr.  Knaben.  Prag.  med.  Wochenschr., 
Bd.  23,  1898,  p.  585.—Franke.  Ueber  Hauthorner.  Arch.  f.  klin.  Chir.,  Bd.  34,  1887, 
p.  937. — Mitvalsky.  Ein  Beitrag  zur  Kenntnis  der  Hauthorner  der  Augenadnexa. 
Arch.  f.  Dermatol.,  Bd.  27,  1894,  p.  47. — Saxer.  Ependyniepithel,  Gliome  und  epithelial 
Geschwiilste  des  Zentralnervensystemes.  Zieglers  Beitr.  z.  path.  Anat.,  Bd.  32,  19U0, 
papilljire  Tumoren,  p.  320. — Spietschka.  Beitrag  zur  Histologie  des  Cornu  cutaneum. 
Arch.  f.  Dermatol.,  Bd.  42,  1898,  p.  39. 

(b)  ADENOMAS 

Adenomas  are  fibroepithelial' tumors  in  which  the  epithelial  cells 
have  a  glandular  arrangement.  The  finer  structure  of  the  tumor,  the 
form  of  the  cells,  and  their  secretory  function  depend  upon  the  char- 
acter of  the  tissue  from  which  the  tumor  springs. 

Adenomas  of  the  glands  of  the  skin  and  mucous  membranes  differ 
from  hyperplastic  growths  in  that  they  do  not  reproduce  the  form  and 
structure  of  the  normal  glands.  Adenomas  of  the  glandular  organs 
differ  from  inflammatory  hyperplasias  in  being  encapsulated  and  in 
having  no  functicmal  connection  whatever  with  the  surrounding  tissues 
(Ribbert). 

The  majority  of  adenomas  are  benign  growths.  Some  forms,  how- 
ever, invade  the  surrounding  tissues  and  blood  vessels,  forming  metas- 
tases. 

Cystadenomas  may  be  regarded  as  a  variety  of  this  class  of  tumors. 
Cystadenomas  form  wiien  gland  tubules  become  dilated  by  secretion 
poured  out  by  the  cells  or  when  liciuefaction,  following  regressive 
changes  in  the  cells,  occui'S. 

ADENOMAS   OF   THE    SKIN 

Adenomas  of  the  skin  are  veiy  rare  and  cannot  always  be  easily 
differentiated  from  simple  hyperplasias  of  the  glands  of  the  skin.     A 


904  DIFFERENT   VARIETIES   OF  TUMORS 

carcinoma  of  the  skin  may  develop  ui)on  an  adenoma.  It  .should  be 
mentioned  that  if  the  adenoma  is  singh>  and  ulcerated  the  mistaken  diag- 
nosis of  carcinoma  ma.y  be  made. 

Adenomas  of  the  sebaceous  glands  (adenomata  sebacea)  are  most 
common  upon  the  face,  especially  upon  the  nose  and  eyelids,  occurring 
as  single  or  multiple  tumors.  The  tumors  are  soft  and  well  encapsu- 
lated, vary  in  size  from  a  pea  to  a  walnut,  have  a  warty  or  nodular 
form,  and  a  red,  slightly  transparent  or  pearllike  appearance.  They 
lie  within  the  skin,  and  the  epithelial  lobules  composing  the  tumor,  which 
resemble  sebaceous  glands,  are  imbedded  in  a  connective-tissue  stroma. 
These  tumors  are  most  common  in  old  people,  and  grow  slowly.  At 
times  they  develop  upon  an  old  seborrheic  eczema  and  may  ulcerate, 
after  some  superficial  injury  or  as  the  result  of  regressive  changes  in 
the  epithelium  or  hyaline  degeneration  of  the  connective  tissue  and 
blood  vessels.  They  may  become  calcified  (so-called  calcified  epitheli- 
oma)  or  transformed  into  a  carcinoma  (Barlow,  von  Noorden,  Thorn). 

They  may  easily  be  mistaken  for  endotheliomas,  and  can  scarcely 
be  differentiated  from  adenomas  of  the  sweat  glands.  If  ulcerated  they 
may  be  mistaken  for  a  flat  carcinoma  of  the  skin,  especially  if  the  skin 
surrounding  the  ulcer  has  become  thickened  and  indurated  as  the  result 
of  inflammation. 

They  disappear  after  the  use  of  strong  caustics  and  the  X-ray.  In 
the  treatment  of  larger  tumoi-s,  excision  is  to  be  preferred  because  heal- 
ing is  much  more  rapid. 

Adenomas  of  the  sweat  glands  (adenomata  sudoripara)  are  also 
rare.  They  occur  as  single,  occasionally  multiple,  nodules  of  the  skin 
and  subcutaneous  tissue.  According  to  Konig,  the  multiple  forms  re- 
semble lupus  nodules.  These  tumors  are  most  common  in  the  face 
(forehead,  temporal  regions,  nose,  lips,  chin)  and  in  the  scalp,  but  also 
occur  in  the  skin  of  the  breast  and  back,  about  the  navel,  in  the  inguinal 
regi(ms,  about  the  labia,  and  upon  the  extremities   (vide  Klauber). 

They  may  develop  in  early  childhood,  but  are  most  connnon  in  old 
people  from  fifty  to  sixty  years  of  age.  They  grow  slowly.  The  tumors 
developing  in  the  skin  appear  as  small  nodules  or  pale  sausagolike  ele- 
vations of  the  skin,  while  the  suljcutMneous  tumors  are  covered  for  a 
long  time  by  normal  skin,  which,  however,  cannot  be  raised  from  the 
growth.  Larger  forms,  the  size  of  n  plate  or  a  child's  head,  have  been 
observed  (Klauber,  Jupunoff).  These  larger  growths,  which  are  pedun- 
culated and  fungiform  in  shape,  fre(|U(>ntly  ])ecome  ulcernted  and  covered 
with  eiMisjs.  Tlie  consistency  of  these  growths  vnries,  depending  upon 
wliellici-or  not  cysts  develop.  Chronic  ulcers,  fi-oiii  which  fint,  su]Hn'ficial 
e;ireiii()iiiiis  uiny  develop,  follow  regressive  clinnges  in  an  ;i(lenoma. 

Adenonuis  of  the  sweat  glands  consist  of  dilated  and  cystic  gland 


FIBROEriTHELIAL   TUMORS  905 

tubules  lined  with  eyliiulricjil  (>})itlieliuin,  ANliicli  may  be  arranged  ia 
the  form  of  papillary-  growths.  These  tumors  contain  relatively  large 
amounts  of  connective  tissue,  and  are  sharply  defined  against  the  sur- 
rounding tissues.  They  may  occur  in  parts — for  example,  the  upper 
lip — where  normally  there  are  no  sweat  glands,  suggesting  that  some  of 
these  tumors  arise  from  a  congenital  anlage. 

The  diagnosis  is  not  simple.  The  tumors  have  no  definite  character- 
istics which  enable  one,  when  they  are  situated  in  the  skin,  to  differ- 
entiate them  from  adenomas  of  the  sebaceous  glands,  or  if  in  the  sub- 
cutaneous tissues,  from  lipomas  or  lymphangiomas.  It  is  possible,  even 
upon  microscopic  examination,  to  confuse  them  with  the  last  and  with 
endotheliomas.  According  to  Borst,  displaced  germinal  breast  tissue 
should  be  considered  in  the  diagnosis  when  the  tumors  occur  in  the  skin 
covering  the  breast  and  in  that  of  the  back. 

The  same  treatment  as  described  in  discussing  adenomas  of  the  seba- 
ceous glands  should  be  instituted  for  these  tumors. 

Literature. — Barlow.  IJeber  Adenomata  sebacea.  Deutsch.  Arch.  f.  klin.  ]\Ied., 
Bd.  55,  1895,  p.  61. — Coenen.  Ueber  Endotheliome  d.  Haut.  Arch.  f.  kliii.  Chir., 
Bd.  76,  1905,  p.  1100. — Klauber.  Ueber  Schweissdriisentumoren.  Beitr.  z.  klin. 
Chir.,  Bd.  41,  1904,  p.  311. — v.  Noorden.  Das  verkalte  Epitheliom.  Beitr.  z.  klin. 
("liir.,  Bd.  3,  1888,  p.  467. — Perthes.  Ueber  gutartige  Epitheliome  wahrscheinlich 
kongenitalen  Ursprunges.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  65,  1903,  p.  283. — Thorn. 
Ueber  das  verkalkte  Epitheliom.  Arch.  f.  klin.  Chir.,  Bd.  56,  1898,  p.  781.— Stilling. 
Einige  Beobachtungen  zur  Anatomie  und  Pathologic  des  Lupus.  Deutsche  Zeitschr.  f. 
Chir.,  Bd.  8,  1877,  p.  72. 

ADENOMAS    OF    THE   MUCOUS   MEMBRANE 

The  glands  occurring  in  nnicous  membranes  are  usually  involved  in 
all  the  inflammatory  growths  affecting  the  latter,  leading  frequently,  in 
the  nose  and  its  accessory  sinuses  and  in  the  intestinal  canal  and  urinary 
passages,  to  the  formation  of  polypoid  growths,  the  greater  part  of 
which  is  composed  of  loose  connective  tissue  which  has  proliferated  as 
the  result  of  chronic  inflammation.  As  adenomas  of  the  mucous  mem- 
branes occur  most  frequently  as  polyps,  more  rarely  as  flat  tumors  with 
broad  bases,  it  is  exceedingly  difficult  to  differentiate  between  a  true 
and  an  inflammatory  new  growth,  or,  in  other  words,  between  an  ade- 
noma of  the  mucous  membrane  and  a  glandular  hyperplasia.  The  find- 
ing of  glands  in  the  polyps  which  do  not  correspond  in  form  to  the 
glands  normally  occurring  in  the  part — for  example,  the  occurrence  of 
branched  tubules  in  a  polyp  composed  of  Lieberkiihn's  glands — is  indic- 
ative of  an  adenoma. 

Clinical  Characteristics  of  Adenomas  of  Mucous  Membranes. — Ade- 
nomas of  the  mucous  membranes  are  benign  tumors  which  never  invade 
the  deeper  tissues.  The  submucosa  and  muscularis  mucosae  are  the  only 
58 


906 


DIFFERENT   VARIETIES   OF   TUMORS 


connective  tissues  involved  in  these  growths.  They  clififer  in  form  and 
size.  Their  surfaces,  which  are  covered  by  tissue  resembling  normal 
mucous  membrane,  are  flat  or  somewhat  nodular. 

Hypertrophied  and  cystic  mucous  glands  with  watery  contents  are 
found  in  the  connective-tissue  stroma  of  the  adenomas  of  the  nasal  mu- 
cous membrane,  which  occur  as  soft  polyps  or  as  pedunculated,  grapelike 
tumors. 

Adenomas  of  the  Gastrointestinal  Tract. — Adenomas  of  the  gastro- 
intestinal tract  occur  as  single  or  multiple  tumors.     Frequently  they 

appear  in  the  form  of 
polyps  with  thin  ped- 
icles, varying  in  size 
from  that  of  a  pea  to 
that  of  a  fist,  with 
smooth,  nodular  or 
villous  surfaces;  more 
rarely  as  flat,  circum- 
scribed, soft  thicken- 
ings of  the  mucous 
membrane. 

In  the  stomach  they 
occur  most  frequently 
in  the  pyloric  region, 
developing  from  the 
pyloric  glands.  If 
they  are  so  situated  and  become  large  enough,  they  may  obstruct  the 
pyloric  orifice  and  be  diagnosed  clinically  as  carcinoma.^ 

Adenomas  of  the  intestinal  canal  develop  from  Lieberkiilm's  glands; 
those  occurring  in  the  duodenum  from  Brunners  glands  (Salvioli). 
The  single  adenomas  may  occur  in  any  part  of  the  intestinal  canal,  but 
they  are  found  most  frequently  in  the  lower  part  of  the  rectum,  develop- 
ing in  cliildi-eii  as  well  as  in  adults.  The  pedicle  of  such  a  tumor,  which 
is  usually  roinid  and  never  becomes  larger  than  a  walnut,  may  be 
stretched  by  tlie  fa'ces  passing  over  it  or  as  the  result  of  fre(iuent  pro- 
lapse until  it  becomes  several  centimeters  in  length. 

Frequently  hasmorrhage  following  stool  or  prolapse  of  the  nnicous 
membrane  is  the  first  symptom  of  a  tumor  of  this  character. 

The  presence  of  such  a  tumor  may  be  easily  determined  by  digital 
examination  of  the  rectum. 


'^ImB^U&^MsBB^M 


Fig.  399.— Si; 


•\i  THE  Summit  of  a  Rectal  Polyp. 


>Loxer  once  operated  upon  an  adenoma  of  the  stomach  in  an  adult  which  was  as 
lar^o  as  a  child's  head.  It  was  attac^lied  by  a  thick  pedicle  to  the  nuicous  membrane 
of  the  pylorus.     The  f^rcater  part  of  the  tumor  lay  in  the  fundus. 


FIBROEPITHELIAL  TUMORS  907 

After  the  pedicle  is  put  on  a  stretch  it  should  be  ligated  close  to 
the  mucous  membrane  and  divided.  If  the  polyp  is  torn  during  a  bowel 
movement,  the  spurting  vessel  should  be  caught  by  a  transfixion  suture, 
or  the  bleeding  point  should  be  touched  with  the  actual  cautery. 

Multiple  Adenomas  of  the  Intestines. — ^Multiple  adenomas  of  the  in- 
testine give  rise  to  a  peculiar,  often  severe  clinical  picture.  The  mucous 
membrane  of  the  rectum,  which  is  chiefly  affected,  also  that  of  the  large 
intestine,  and  more  rarely  that  of  the  small  intestine  immediately  adja- 
cent, is  beset  with  numerous,  closely  set,  small  and  large  polypi  (poly- 
posis recti  et  intestini  crassi).  The  symptoms  of  these  multiple  tumors, 
which  occur  in  children  and  young  adults,  begin  with  an  intestinal 
catarrh  which  resists  treatment.  The  discharge  of  blood-stained  masses 
of  mucus  is  suggestive  of  multiple  tumors  of  the  intestinal  mucous 
membrane.    A  history  of  heredity  can  freipiently  be  elicited. 

Profuse  h.pmorrhages  occur  in  rapid  succession,  producing  a  marked 
anaemia.  Occlusion  of  the  bowel  by  the  larger  tumors,  invagination  of 
intestinal  loops  as  the  result  of  continual  traction  (e.  g.,  invagination 
of  the  colon  into  the  rectum),  and  finally  the  development  of  carcinoma 
(adenocarcinoma)  are  some  of  the  complications.  Twelve  of  the  eight- 
een cases  collected  by  Rotter  died. 

The  diagnosis  is  made  certain  by  an  examination  of  the  rectum. 

Similar  adenomatous  polyps  occur  in  the  uterine  mucous  membrane 
and  in  young  children  about  the  umbilicus.  The  latter  develop  from 
remains  of  the  vitelline  duct. 

These  adenomas  are  to  be  regarded  as  the  result  of  developmental 
disturbances,  originating  from  pieces  of  mucous  membrane  which  have 
been  displaced  and  have  become  independent  of  the  surrounding 
tissues. 

Treatment. — In  the  treatment  an  attempt  should  be  made  to  remove 
all  the  tumors  which  are  accessible  through  the  rectum.  It  will  be 
necessary  to  perform  a  laparotomy  in  order  to  remove  the  adenomas 
situated  in  the  higher  intestinal  loops.  If  the  tumors  have  broad  bases 
it  will  be  necessary  to  circumscribe  them  and  remove  a  portion  of  the 
wall  of  the  stomach  or  intestine  adjacent  to  them,  closing  the  defect  in 
the  ordinary  way.  If  the  tumor  has  a  long  pedicle,  all  that  is  necessary 
after  exposing  the  tumor  is  to  ligate  it  close  to  the  mucous  membrane. 
In  polyposis  of  the  large  intestine  the  results  following  even  repeated 
operations  are  only  temporary,  because  of  the  extent  of  the  pathological 
changes. 

Literature. — Port.  Multiple  PolypoTibildung  iin  Tnietus  intestinalis.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  42,  1806,  p.  181. — Rotter.  Verletzungen  unci  I']rkrankungen  ties 
Mastdarmes  und  des  Afters.  Haudb.  d.  prakt.  Chir.,  2.  Aufl.,  lid.  .3,  ]).  GGO. — Schwab. 
Ueber  multiple  Polypenwucherungen  im  Kolon  und  Rektum.      Beitr.  z.  klin.  Chir., 


908 


DIFFERENT   VARIETIES   OF   TUMORS 


Bd.  18,  1897,  p.  353. — Smoler.     Ueber  Adenome  des  Dunn-  und  Dickdarmes.     Beitr. 
z.  klin.  Chir.,  Bd.  36,  1902,  p.  139. 


ADENOMAS  OF  THE  GLANDULAR  ORGANS 

Adenomas  of  the  Salivary  Glands. — These  tumors  are  usually  benign, 
being  circumscribed  and  encapsulated.  Sometimes  they  invade  blood 
vessels  and  form  metastases,  in  this  way  resembling  clinically  a  malig- 
nant growth,  although  they  resemble  closely  the  structure  of  the  organ 
from  which  they  develop  and  would  be  classified  histologically  as  benign 
tumors.  The  relative  amounts  of  epithelial  and  connective  tissues  dif- 
fer in  the  different  tumors,  and  therefore  the  histological  pictures  of 
different  adenomas  vary  a  great  deal.  If  the  connective  tissue  predomi- 
nates, the  tumor  is  hard  and  of  about  the  same  consistency  throughout, 
resembling  a  fibroma;  therefore  the  term  fibroadenoma.  If  the  con- 
nective tissue  is  very  cellular,  the  tumor  is  spoken  of  as  an  adeno- 
sarcoma;  if  mucoid,  as  an  adenomyxofibroma  (cystosarcoma  phyllodes, 
myxofibroma  intracanaliculare).  The  epithelial  cells,  which  are  usually 
arranged  in  a  single  layer,  may  be  cylindrical,  cubical,  flat,  or  very 
irregular,  and  may  form  tubules  which  resemble  ducts  (tubular  ade- 
noma) or  alveoli  (alveolar  adenoma).  If  the  tubules  or  alveoli  be- 
come  transformed   into    cysts,    a   cystadenoma   develops.      If   branched 

papillary    growths    develop 


;'^^^>"*?5'i-:;',^ 


^o^ 


\-^ 


in  the  tubules  or  cysts,  an 

adenoma  or  cystadenoma 

i^w-'.^  '      .  /'.      papilliferum  (papilloma, 

&.^y  • .;  .  '■:■.:■'  '■'.■£.  V-'%  i     fibroma     intracanaliculare) 

is  formed. 

Adenomas  of  the  Mam- 
mary Gland. — Adenomas  of 
the  mammary  gland  appear 
as  round,  slowly  growing 
nodules  of  different  sizes 
and  consistency.  They  may 
occur  as  multiple  tumors  in 
one  or  both  breasts,  are 
/■•'■'    ''    ''i'\  \\  ^^^'^^   encapsulated   and   be- 

.J^M   </0j''l.\  m       __J     iiign,  but  recur  after  incom- 

Fio.  4{J().— Cystic  Adenoma  of  the  Pahotid  Gland.       pl^te    removal    from    picCCS 

which  are  left  behind.  Be- 
ciiiisc  of  their  cucMpsuhition  they  can  be  easily  differentiated  from  dif- 
fuse hyijerphisia  of  the  breast.  Adenomas  of  Ihe  breast  are  frequent 
in  young  v/omen,  but  extremely  rare  in  men.  They  may  attain  con- 
siderable si7.e,  especially  the  cystic  forms.     Finally,  the  skin  covering 


"v. 


'1 


FIBROEPITHELIAL  TUMORS 


909 


^•''ff'%'\*  *.f  t'."f  :/i(  ,'trv •//,■•'•''  ,ji^  '-■-•■-    W  •■•-'.  -i^ 


tliose  tumors,  wliieli  liad  Ix-cn  luicluin.ucd  and  perfectly  iiiovahle,  under- 
goes a  pressure  atrophy  and  becomes  necrotic.  The  tumor  is  then  ex- 
posed and  develops  above  the  level  of  the  skin.  The  simple  tubular  and 
alveolar  adenomas  are  hard,  rich  in  connective  tissue,  and  upon  section 
have  a  homogeneous, 
grayish  red  color 
(fibroadenomas).  If 
they  develop  from 
large  tubules  resem- 
bling ducts  of  the 
gland,  large  tortu- 
ous spaces  and  cysts 
form,  which  can  be 
seen  upon  section. 
The  tumor  is  then 
spoken  of  as  a  cyst- 
adenoma.  If  connect- 
ive-tissue processes, 
carrying  the  epithe- 
lium with  them,  de- 
velop into  the  spaces, 
largo  cysts  filled 
w  i  t  h  pedunculated, 
papillary,  villous,  or 

grai^elike  growths  are  formed  (cystadenoma  papillare.  papilliferum,  or, 
depending  upon  the  character  of  the  stroma,  fibroma  or  myxonui  intra- 
canaliculare,  sarcoma  arborescens,  phyllodes). 

Mastitis  Chronica  Cystica. — A  disease  of  the  breast  occurring  fre- 
quently, especially  in  old  women,  and  characterized  by  the  fornuition  of 
multiple  cysts  in  one  or  both  breasts,  is  regarded  by  Schimmelbusch  as 
multiple  cystadenoiuas ;  by  Konig,  because  of  its  clinical  course,  as  a 
chronic  inflammation  (mastitis  chronica  cystica).  Upon  section,  small 
and  large,  brownish  cysts  are  seen  in  the  tissue  of  the  breast,  which  is 
usually  enlarged. 

Adenomas  of  the  Thyroid  Gland. — Adenomas  of  the  thyroid  gland 
are  nodular  and  circumscribed,  ditfering  from  the  diffuse  or  local  hyper- 
plasias which  occur  in  the  uuijority  of  goiters.  The  adenomas  occurring 
in  this  gland  gradually  enlarge  and  may  become  as  large  as  an  apple. 
They  may  be  congenital  and  are  frequently  multiple.  Occasionally  an 
adenoma  of  the  thyroid  becomes  malignant,  producing  a  pressure 
atrophy  of  the  wall  of  a  vein  and  invading  its  lumen.  Cells  are  then 
carried  by  the  blood  stream  and  develop  in  different  viscera  and  tissues. 
Slowly   developing,   secondary   nodules   then   appear  in  the  lungs  and 


Fig.  401. — Cystadenoma  of  the  Mammary  Gland,  (a,  Alveo- 
lar Arrangement  of  Epithelium,  at  other  Points  a  Tu- 
bular Arrangement.) 


910 


DIFFERENT   VARIETIES  OF   TUMORS 


bones  where  the  cells  find  conditions  most  favorable  for  development. 
Gradually  the  bone  involved  undergoes  pressure  atrophy  and  spontane- 
ous fractures  may  occur.  [It  has  not  been  satisfactorily  explained  why 
adenomas  and  carcinomas  of  the  thyroid  gland  are  followed  so  frequently 
by  the  formation  of  secondary  growths  in  bone.  It  should  be  remem- 
bered in  this  connection  that  carcinomas  of  the  breast  and  prostate  and 
hypernephromas  are  also  frequently  associated  with  secondary  deposits 
in  bone.] 

Hypernephromas. — Adenomas  of  the  adrenal  glands  (strumte  supra- 
renales,  hypernephromas)  appear  as  circumscribed  nodules,  the  char- 
acter of  which  may  be  easily 
recognized  by  the  bright  yel- 
low color.  These  tumors,  re- 
sembling histologically  the  cor- 
tex of  the  adrenal  glands,  de- 
velop from  misplaced  adrenal 
tissue.  They  occur  in  the  ad- 
renal gland  and  kidney  (being 
probably  the  most  frequent 
tumor  occurring  in  the  latter 
organ)  ;  more  rarely  in  the 
broad  ligament,  in  the  epididy- 
mis, and  on  the  under  surface 
of  the  liver.  Developing  from 
adrenal  rests  lying  in  the  cor- 
tex, they  may  form  large  tu- 
mors in  the  kidney  and  destroy 
almost  all  of  the  normal  kidney 
tissue.  If  they  rupture  through 
their  capsule,  these  tumors  in- 
vade the  renal  vein  and  lead 
to  the  formation  of  extensive 
metastases. 

Adenomas  of  the  Kidney. — 
Adenomas  of  the  kidney  occur 
as    single    or    multiple    encap- 
sulated  grayish   white   tumors 
which   rarely   become   malignant.      They   never   become   larger   than    a 
cherry,  and  are  composed  either  of  tubules  or  cysts  filled  with  papil- 
lary ingrowths. 

Adenomas  of  the  Liver.— Adenomas  of  the  liver  are  composed  of  solid 
Or  hollow  cell  columns.  They  occur  as  round,  soft, light  brown  nodules, 
or  at  times  as  large  pedunculated  tumors  in  the  margin  of  the  liver  (von 


Fig.  402. — Mamc.nant  Hypernephroma  of  thk 
Kidney.  (Woman  thirty-five  years  of  age.) 
a,  Upper  half  of  kidney  not  involved  by  the 
growth;  b,  tiniior. 


fibroepitheliaL  tumors  911 

Borgmann).  These  tumors  are  uneouiinon.  IMaiiy  have  a  tendency'  to 
an  mfiltrating  and  malignant  growth,  as  they  invade  the  radicles  of 
the  portal  and  hepatic  veins  and  form  metastatic  growths.  According 
to  Rit)bert,  the  development  of  multiple  tumors  which  are  histologically 


\::,.*ffi-;.:  .■••■'<....';,■'«.''.'•.•.        '  ■'.^,/ ■,'':-•  •'    '.•..:•..''•/./ 

Fig.  403. — Section  from  a  liYPEK.NLi-iiKuMA. 
(From  Professor  Bevan's  Surgical  Clinic.) 

adenomas  is  best  explained  in  this  \\Q.y.  In  spite  of  the  tendency  of 
these  tumors  to  invade  the  vessels,  metastases  (in  the  lungs,  lymph  nodes, 
and  bones)  are  relatively  rare. 

ORIGIN    OF    ADENOMAS 

Adenomas  develop  from  germinal  tissue  which  has  been  displaced 
and  encapsulated  in  the  parenchyma  of  the  organs  in  which  they  de- 
velop, forming  independent  centers  of  growth.  The  hypernephroma, 
which  develops  from  adrenal  tissue  displaced  into  the  cortex  of  the 
kidney,  is  the  most  striking  example  of  this.  The  diagnosis  and  treat- 
ment of  adenomas  of  the  different  organs  belong  to  special  surgery. 

The  cj^stic  growths  which  occur  in  a  number  of  organs  and  are  prob- 
ably due  to  developmental  disturbances  should  be  mentioned  before  clos- 
ing the  chapter  upon  adenomas. 

The  cysts  or  cystadenomas  which  occur  so  frequently  in  the  ovaries 
should  be  mentioned  first.     These  growths  appear  as  large  unilocular 


912  DIFFERENT   VARIETIES   OF   TUMORS 

or  nniltiloeiilar  cysts  in  one  or  both  ovaries.  The  cysts  are  lined  with 
cylindrical  epithelial  cells  which  in  some  cases  have  proliferated  to 
form  papillary  growths.  The  epithelium  may  have  a  glandlike  arrange- 
ment. If  the  villous  or  papillary  growths  break  through  the  cyst  wall, 
the  peritoneum  becomes  involved  and  the  pelvis  and  the  lower  part  of 
the  abdominal  cavity  may  become  filled  with  papillary  growths. 

In  congenital  cystic  disease  of  the  kidney  and  liver  these  viscera  are 
completely  filled  with  small  and  large  cysts  (multilocular  cystadenomas}. 

Literature. — Beer.  Ueber  Nebennierenkeime  in  der  Leber.  Zeitschr.  f.  Heilkunde, 
Bd.  25,  1904,  p.  SSL — v.  Bergmann.  Zur  Kasuistik  der  Leberchirurgie.  Chir.-Kongr. 
VerhandL,  1893,  II,  p.  218. — Buday.  Beitrage  z.  Zystenbildimg  in  den  suprarenalen 
Nierengeschwiilsten.  Zieglers  Beitr.  z.  path.  Anat.,  Bd.  24,  1898,  p.  501. — Dobbertin. 
Beitrag  z.  Kasuistik  der  Geschwiilste.  Ibid.,  Bd.  28,  1900,  p.  42. — Gierke.  Ueber 
Knochentumoren  mit  Schilddriisenbau.  Virchow's  Arch.,  Bd.  170,  1902,  p.  464. — 
Goebel.  Ueber  eine  Geschwulst  von  schikldriisenartigem  Ban  im  Femur.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  47,  1898,  p.  348. — Hildebrand.  Beitrag  zur  Nierenchirurgie. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  40,  1895,  p.  90; — Weiterer  Beitrag  zur  pathol.  Anatoniie 
der  Nierengeschwiilste.  Arch.  f.  khn.  Chir.,  Bd.  48,  1894,  p.  343; — Ueber  den  Bau 
gewisser  Nierentumoren,  ihre  Beziehung  zu  den  Nierenadenomen  und  zur  Nebennicre, 
nebst  Mitteilungen,  iiber  den  Glykogenbefund  in  diesen,  sowie  in  anderen  Geschwiilsten. 
Arch.  f.  khn.  Chir.,  Bd.  47,  1894,  p.  225. — Hoist.  Ueber  doppelseitige  primare  Neben- 
nierentumoren.  I.-D.,  Leipzig,  1904. — Morris  Wolff.  Beitrag  zur  Kenntnis  der 
Tumoren  der  Mamma.  I  -D.,  Rostock,  1899. — Rehbcrg.  Untersuchungen  iiber  die 
Adenome  der  Nieren  und  ihre  Entwicklung.  I.-D.,  Freiburg,  1902. — Sasse.  Ueber 
Zysten  und  zystische  Tumoren  der  Mamma.  Arch.  f.  klin.  Chir.,  Bd.  54,  1897,  p.  1. — 
Schimnu'lbusch.  Das  Fibroadenom  der  Mamma.  Ibid.,  Bd.  44,  1892,  p.  102; — 
Das  Zystadenom  der  Mamma.  Ibid.,  Bd.  44,  1892,  p.  117. — Sudeck.  Ueber  die 
Struktur  der  Nierenadenome.  Ihre  Stellung  zu  den  Strumae  suprarenales  aberratae. 
Virchows  Arch.,  Bd.  133,  1893,  p.  405; — Zur  Lehre  von  den  aberrierten  Nebennierenge- 
schwiilsten  in  der  Niere.     Ibid.,  Bd.  136,  1894,  p.  293. 


(c)  EPITHELIAL    CYSTS 

This  group  comprises  tumors  the  majority  of  which  develop  in  the 
beginning  as  cysts.  They  are  composed  of  epithelium  and  connective  tis- 
sue. According  to  Ribbert,  they  may  be  classified  with  the  fibroepithelial 
tumors,  although  many  are  closely  related  to  the  mixed  tumors. 

DERMOIDS   OR    DERMOID    CYSTS 

These  lumors  usually  occur  singly,  appearing  in  the  first  few  years 
of  life.  They  are  spherical  or  hemispherical  in  shape,  depending  upon 
the  tciisidii  and  ])ressure  exerted  by  the  soft  tissues  covering  them. 

Wall  Lining  and  Contents. — The  walls  of  these  cysts  are  fairly  thick 
and  resistant.  The  outer  surface  is  smooth,  while, the  inner  surface  is 
rough,  of  a  whitish  color  and  covered  with  numerous  fine  and  short,  or 
thick  and   long  hairs.     The  inner  layer  of  the  cyst  wall  is  quite  like 


FIBHOEPITHELIAL  TUMORS  913 

skin,  as  it  contains  epidermis,  papilke,  hair,  sebaceous  and  sweat  glands. 
The  outer  layer,  consisting  of  firm  connective  tissue,  the  inner  part  of 
which  forms  the  connective  tissue  of  the  papilhe,  is  h)osely  attached  to 
the  surrounding  tissue,  and  therefore  the  majority  of  these  cysts  can  be 
easily  enucleated  without  rupturing  the  wall.  When  occurring  about 
the  head,  they  may  be  firmly  attached  to  the  periosteum.  The  epithelial 
lining  in  many  dermoids  is  incomplete.  Where  the  lining  is  incomplete 
the  epithelium  is  replaced  by  connective  tissue  rich  in  large  polynuclear 
giant  cells.  The  areas  of  different  sizes,  in  which  the  epithelium  is  not 
present,  are  brown  in  color,  smooth,  and  round  (Fritz  Konig).  The 
giant  cells  frequently  contain  hair  and  fat  crystals,  and  are  to  be  re- 
garded as  foreign  body  giant  cells.  The  contents  of  a  dermoid  cyst  are 
a  cheesy,  yellowish-white  mass,  consisting  of  desquamated  cells,  the  secre- 
tion of  the  sebaceous  and  sweat  glands,  numerous  drops  of  fat,  fat 
crystals,  and  cholesterin  plates.  Sometimes  the  contents  are  of  a  watery 
or  serous  character,  or,  after  a  ha3morrhage,  of  a  reddish  brown  color. 

Dermoid  cysts  occur  in  definite  positions  and  are  the  result  of  de- 
velopmental defects.  They  are  found  where,  during  embryonal  life, 
there  were  clefts,  furrows,  or  depressions  of  the  surface  of  the  body 
which  later  close,  or  where  there  were  invaginations  of  the  ectoderm. 
During  the  process  of  development  cutaneous  germinal  tissue  becomes 
buried  beneath  the  skin  and  gradually  develops  to  form  cysts.  There- 
fore these  tumors  usually  occur  in  childhood  and  lie  more  frequently 
just  beneath  the  skin  than  at  a  deeper  level. 

Dermoids  of  the  Head  and  Neck. — Dermoids  of  the  head  and  neck 
are  the  most  common.  Dermoids  about  the  eye  develop  from  pieces  of 
ectoderm  which  are  displaced  during  the  invagination  of  the  ectoderm 
to  form  the  lens  or  during  the  fusion  of  the  maxillary  with  the  naso- 
frontal process.  They  occur  most  commonly:  (1)  Along  the  supraorbital 
ridge,  at  the  outer  canthus  of  the  eye,  about  the  glabella,  at  the  root  of 
the  nose,  or  at  the  outer  extremity  of  the  orbital  ridge;  (2)  within  the 
orbit.  The  dermoids  occurring  along  the  orbital  ridge  appear  as  round 
growths,  varying  in  size  from  that  of  a  pea  to  that  of  a  walnut.  Those 
occurring  in  the  orbit  produce  an  exophthalmos.  They  are  covered  by 
normal  skin,  which  may  be  easily  displaced  over  the  tumor,  and  lie 
directly  beneath  the  skin  or  beneath  the  galea  aponeurotica,  the  frontal 
portion  of  the  occipito-frontalis,  or  the  orbicularis  oculi.  When  der- 
moids are  deeply  situated  they  sometimes  produce  changes  in  the  bones 
about  the  orbit  or  in  the  other  skull  bones  over  Avhich  they  are  situated. 
When  the  dermoid  lies  directly  upon  the  bone,  a  shallow  depression 
with  raised  edges  may  be  formed.  Sometimes  the  depression  may  ex- 
tend through  the  bone,  and  then  the  tumor  comes  in  contact  with  the 
dura  mater  or  the  contents  of  the  orbit.     Occasionally  a  dermoid  lying 


914 


DIFFERENT   VAKll'jriES   OF   TUMORS 


outside  of  the  orbit  communicates  by  a  narrow  process  with  another 
cyst  lying  within  the  orbit.  These  cysts,  communicating  with  each  other 
(Zwerschsackdermoide  of  Kronlein)  are  not  formed  by  the  fusion  of 
two  separate  cysts,  but  during  the  development  of  the  cranial  and  facial 

bones  the  preexisting 
cyst  is  surrounded  by 
the  bone  and  a  part 
of  the  cyst  is  con- 
stricted to  form  the 
intermediate  portion 
between  the  two  parts. 
When  the  bone  is  fully 
developed  a  part  of 
the  cyst  lies  without, 
a  part  within  the 
orbit. 

Dermoids  also  oc- 
cur at  other  points  in 
the  head,  where,  dur- 
ing development,  the 
ectoderm  can  be  in- 
V a gin a ted  easily. 
They  occur  about  the 
anterior  and  posterior 
fontanelles,  about  the 
ear,  just  in  front  of 
the  tragus,  or  over 
tlic  mastoid  jji'oeoss  (developing  from  the  aural  anlage  and  the  first 
bi';ni('lii;il  clcri).  They  also  occur,  but  very  rarely,  on  the  face,  on  the 
(lorsuiii  ;md  Jibout  the  point  of  the  nose,  developing  from  the  median 
n;isal  furrow  (von  Brnmaun,  Lamielongue) ,  in  the  cheek,  at  the  side 
of  the  aJu'  nMsi,  (lev(^lo])iiig  from  the  naso-orbital  cleft  (von  Bramann), 
in  the  middle  of  the  cheek,  developing  from  the  transverse  cleft  of  the 
clieek  Ix'tvveen  the  maxillary  and  mandibular  processes  (Lannelongue, 
Verneuil,  Lexer). 

It  is  striking  that  dermoids  occur  much  more  frequently  about  some 
of  the  embryonal  clefts  than  others.  Dermoids  never  occur  about  those 
clefts,  fusion  of  the  edges  of  which  is  easily  prevented  giving  rise  to 
a  number  of  different  developmental  disturbances,  such  as  lateral  labial 
fissure,  harelip,  or  cleft  palate.  Von  B>i-amauii  ])elieves  that  the  piece 
ol"  ccjodcnii  loniiing  Ihc  dcniioid  anlage  is  most  frecfuently  constricted 
olT  jihout  those  fissures,  which  are  closed  veiy  early  by  the  fusion  of  their 
boi'ders.     At  the  time  of  the  closing  of  these  clefts  the  i)roamnion  is 


Fig.  404. — Dermoid  Cyst  at  the  Outer  End  of  the  Supra- 
orbital Ridge. 


FIBROEPITHELIAL  TUMORS  915 

closely  related  to  tlie  head,  and  there  is  more  clianee  for  the  displace- 
ment of  pieces  of  ectoderm  during  the  closure  of  the  cleft  or  the  in- 
vagination of  the  ectoderm  to  form  the  lens,  caused  by  adhesions  with 
the  proanniion,  than  after  formation  of  the  true  anniion.  Dermoids  do 
not  develop  about  the  clefts  that  close  later  for  the  reason  above  given. 

Dermoids  of  the  neck  occur  most  frequently  in  the  lateral  regions 
just  below  the  submaxillary  glands.  When  they  occur  in  this  position 
they  are  covered  by  the  platysma  and  reach  from  the  inner  border  of 
the  sterno-cleido-mastoid  to  the  digastric  muscle.  AVhen  they  attain 
considerable  size  they  develop  posteriorly  beneath  the  sterno-cleido-mas- 
toid muscle.  Dermoids  occurring  in  the  position  above  mentioned  de- 
velop from  the  second  branchial  cleft.  More  rarely  these  cysts  lie  in 
the  median  line  of  the  neck  directly  beneath  the  skin,  sometimes  above, 
at  other  times  below  the  larynx,  or  in  the  jugulum  (fusion  of  the 
branchial  clefts,  sinus  cervicalis).  The  dermoids  occurring  in  the  floor 
of  the  mouth  usually  lie  between  the  genioglossus  muscles,  extend  toward 
the  tongue,  and  elevate  the  mucous  membrane  of  the  floor  of  the  mouth. 
In  rare  cases  these  tumors,  resulting  from  imperfect  fusion  of  the  halves 
of  the  upper  branchial  arches,  form  on  the  outer  side  of  the  myelo- 
hyoid  muscle,  and  then  they  are  covered  only  by  the  skin  of  the  sub- 
mental region. 

Dermoids  Occurring  in  Other  Parts. — The  following  positions  in  which 
dermoids  also  occur  should  be  mentioned:  (1)  Dermoids  of  the  chest, 
situated  in  the  anterior  or  posterior  mediastinum,  which,  like  those  oc- 
curring in  the  abdominal  wall  about  the  navel  or  in  the  omentum  and 
mesentery,  are  formed  from  pieces  of  ectoderm  invaginated  during  the 
closure  of  the  thorax  and  abdominal  wall.  (2)  Dermoids  of  the  pelvic 
connective  tissues,  of  which  those  not  connected  with  the  ovary  or  con- 
stricted oft'  from  it  develop  from  eetoderju  invaginated  from  the  ])eri- 
neum.  (3)  Cysts  of  the  retroperitoneal  connective  tissue,  which,  like 
those  occurring  along  the  spermatic  cord  (Wrede),  develop  from  the 
ectodermal  remains  of  the  Wolffian  duct.  (4)  The  extremely  rare  der- 
moids of  the  scrotum,  penis,  and  raphe,  which  are  formed  during  the 
formation  of  the  pei'iiieum  or  the  fusion  of  the  aniage  of  the  external 
genitalia.  (5)  Dermoid  cysts  occuri'ing  in  the  saeral  or  coccygeal  re- 
gions, which  are  relatively  frecjuent  ui)on  the  dorsum  of  the  sacrum 
and  coccyx,  and  often  become  transfoi-iiied  as  the  result  of  infection  or 
traumatism  into  fistula^  which  resist  treatment.  [Some  of  these  cysts 
appear  as  funnel-shaped  invaginations  of  the  skin,  and,  as  they  contain 
hair,  they  are  called  pilonidal  cysts.]  Dermoids  occurring  in  front  of 
the  sacrum  and  coccyx  are  formed  during  the  development  of  the  peri- 
neum or  the  formation  of  the  cloaca.  (6)  Intracranial  dermoids  are 
situated  at  the  base  of  the  brain  between  the  dura  mater  and  bone  or 


916  DIFFERENT   VARIETIES  OF  TUMORS 

within  the  pia  mater.  Dermoids  of  the  vertebral  column,  associated 
with  spina  bitida,  and  of  the  pharynx  are  extremely  rare. 

Dermoids  of  the  testicle  and  ovary  are  rarely  simple.  The  majority 
are  complicated  dermoids,  cysts  containing  a  number  of  different  tissues, 
and  should  l)e  classed  with  the  teratoid  tumors  {vide  p.  980). 

Epidermoids. — In  the  histological  examination  of  many  dermoids  it  is 
found  that  the  lining  of  the  wall  of  the  cyst  is  not  composed  of  the 
cutis,  but  of  many  layers  of  flat  epithelium  containing  papillre  and  the 
stratum  I\Ialpighii,  but  no  hair  or  sweat  glands.  These  tumors  are 
called  epidermoids  and  are  probably  formed  by  the  invagination  of  ger- 
minal cutaneous  tissue  containing  no  glandular  or  hair  anlage.  Perhaps 
the  difference  between  dermoids  and  epidermoids  depends  upon  the  time 
at  which  the  tissue  was  displaced.  It  is  quite  conceivable  that  the 
germinal  tissue  displaced  early  would  be  more  apt  to  form  fully  de- 
veloped skin  than  that  displaced  later.  In  the  post-embryonal  trans- 
plantation of  skin  epithelial  cj^sts  and  not  dermoids  develop. 

According  to  Frank  (p.  989),  some  of  the  atheromas,  those  lying 
subcutaneously,  belong  to  the  class  of  epidermoids,  as  they  develop  from 
germinal  tissue  displaced  during  the  formation  of  the  hair  follicles  and 
sebaceous  and  sweat  glands. 

Suppuration  and  Fistula  Formation. — The  formation  of  a  fistula  fol- 
lowing a  trauma  or  inflammation  is  the  most  important  of  the  changes 
which  may  occur  in  a  dermoid.  Fistula  formation  occurs  most  fre- 
quently in  dermoids  situated  about  the  coccyx,  occasionally  in  those 
situated  about  the  nose.  It  is  indicated  by  the  protrusion  of  a  small 
tuft  of  hair.  Suppuration  of  the  cyst  follows  infections  secondary  to 
injuries,  occasionally  hgematogenous  infections.  In  rare  cases  a  carci- 
noma develops  in  the  cyst  w^all  (II.  Wolff  and  others). 

Diagnosis. — The  diagnosis  is  easily  made.  It  is  based  upon  a  num- 
ber of  characteristics  common  to  dermoids.  The  position  of  the  tumor 
and  its  early  appearance,  even  before  puberty,  are  of  the  greatest  diag- 
nostic significance.  Besides,  the  cysts  are  sharply  circumscribed  and 
smooth,  and  but  slightly  adherent  to  the  surrounding  tissues,  being, 
therefore,  freely  movable.  They  are  covered  by  normal  skin,  which  can 
be  easily  displaced  over  the  tumor.  Their  consistency  differs,  depending 
upon  their  contents.  Frequently  an  indistinct  or  decided  fluctuation 
can  be  elicited ;  often  these  tumors  have  a  doughy  consistency'. 

Dermoids  of  the  head  niid  face  can  usually  be  easily  differentiated 
from  atheromas,  which  are  attached  to  the  skin  at  the  point  at  which 
the  duct  escapes  and  therefore  move  with  it.  Cysts  occurring  at  the 
root  of  tiie  nose,  about  the  glabella,  and  at  the  inner  canthus  of  the 
eye  may  be  easily  confused  with  nasofrontal  and  nasoethmoidal  en- 
cephaloceles,  if  tliey  lie  in  a  depression  in  the  bone  and  give  the  im- 


FIBROEPITHELIAL  TUMORS  917 

pression  of  communicating  with  the  cranial  cavity.  In  making  the 
differential  diagnosis  it  is  important  to  note  whether  thete  are  symptoms 
of  intracranial  pressure  and  whether  the  tumor  decreases  in  size  under 
pressure.  Both  of  these  characteristics  are  often  present  in  encephalo- 
celes.  It  is  scarcely  possible  to  differentiate  retrobulbar  orbital  der- 
moids from  other  varieties  of  tumors.  Dermoids  occurring  in  the  lateral 
regions  of  the  neck  and  the  branchial  cysts,  which  are  genetically  the 
same,  may,  in  spite  of  the  definite  positi(ms  in  which  they  occur,  be 
confused  with  tuberculous  abscesses  and  lipomas.  Examination  should 
l)e  made  for  swollen  adjacent  lymph  nodes,  as  these  would  be  indicative 
of  tuberculosis.  The  smooth  surface  of  the  cyst  may  prevent  mistaking 
it  for  a  lii)oma,  which  is  usually  lolnilated.  Aspiration  is  uncertain. 
Dermoid  cysts  in  the  floor  of  the  mouth  usually  have  a  median  position, 
differing  in  this  way  from  ranulfp,  which  usualh^  are  situated  more  to 
the  sides  of  the  floor  of  the  mouth  cavity. 

Treatment. — Dermoid  cysts  should  be  enucleated.  Enucleation  is  dif- 
ficult only  when  the  wall  has  been  partially  destroyed  by  suppuration. 
If  during  the  removal  of  the  C3^st  any  of  the  wall  is  left,  the  tumor 
rapidly  recurs.  Simple  incision,  permitting  of  the  escape  of  the  con- 
tents of  the  cyst,  is  not  sufficient.  Only  in  very  large  retroperitoneal, 
thoracic,  and  sacrococcygeal  cysts  should  one  be  content  with  this  line 
of  treatment,  as  a  destruction  of  the  sac  cannot  be  expected  after 
drainage. 

Literature. — Aschoff.  Zysten.  Lubarsch  u.  Ostertags  Ergebnisse,  2.  Jahrg. 
Wiesbaden,  1897,  p.  456. — v.  Bramann.  Ueber  die  Dermoide  der  Nase.  Arch.  f. 
klin.  Chir.,  Bd.  40,  1890,  p.  101. — Franke.  Die  Epidermoide  (sog.  Epithelzysten). 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  40,  1895,  p.  197; — Ueber  das  Atherom,  besondera  niit 
Bezug  auf  seine  Entstehung  (das  Epidermoid).  Arch.  f.  kHn.  Chir.,  Bd.  34,  1887,  p. 
507. — Klapp.  Zur  Kasuistik  der  Dermoide  des  Mundbodens.  Beitr.  z.  khn.  Chir., 
Bd.  19,  1897,  p.  608. — Fritz  Konig.  Beit  rage  zur  Anatomie  der  Dermoide  und  Atherom- 
zysten.  Arch.  f.  khn.  Chir.,  Bd.  48,  1894,  p.  164. — Krdnlein.  Dermoide  der  Orbita. 
Beitr.  z.  khn.  Chir.,  Bd.  4,  1889,  p.  149. — Lannelongue  et  Achard.  Traitc  des  kystes  con- 
genitaux.  Paris,  1886. — Lannelongue  et  Minurd.  Affections  congenitales.  Paris, 
1891,  T.  1. — Langner.  Die  angeborenen  Geschwiilste  der  Steissbeingegend  und  des 
Beckenbindegewebes.  I.-D.,  Berhn,  1902. — Lexer.  Ueber  teratoiile  Geschwiilste  in 
der  Bauchhohle  und  deren  Operation.  Arch.  f.  khn.  Chir.,  Bd.  61,  1900,  p.  648. — 
de  Quervain.  Ueber  die  Dermoide  des  Beckenbindegewebes.  Arch.  f.  khn.  Chir., 
Bd.  57,  1898,  p.  129. — Sanger.  Dermoidzysten  des  Beckenbindegewebs.  Arch.  f. 
Gynakol.,  Bd.  37,  1895,  p.  100. — Heinr.  Wolff.  Karzinom  auf  dem  Boden  des  Dermoids. 
Arch.  f.  khn.  Chir.,  Bd.  62,  1900,  p.  731. — Wrede.  Die  Dermoide  des  Samenstranges. 
Beitr.  z.  klin.  Chir.,  Bd.  48, 1906,  p.  273. 

TRAUMATIC    EPITHELIAL    CYSTS 

Not  infrequently  small,  round  cysts,  which  never  become  larger  than 
a  cherry,  are  found  in  the  palm  of  the  hand  and  upon  the  flexor  sur- 


918 


DIFFERENT   VARIETIES  OF   TUMORS 


faces  of  the  fingers.  These  cysts,  resting  upon  the  palmar  fascia  or 
upon  the  sheaths  of  the  flexor  tendons,  may  be  displaced  quite  easily. 
The  skin,  in  which  small  scars  indicating  the  nature  and  origin  of  the 
cyst  may  be  seen,  is  slightly  adherent  to  it.  The  walls  of  the  cysts 
are  composed  of  loose  connective  tissue,  more  or  less  firmly  fused  with 
surrounding  structures,  and  are  lined  by  squamous  epithelium.  The 
contents  are  similar  to  those  found  in  dermoids. 

Etiology. — These  cysts  develop  from  small  pieces  of  skin  which  have 
been  displaced  by  trauma — therefore  have  been  called  traumatic  epi- 
thelial cells  (Garre) — or  originate  from  appendages  of  the  skin  (hair 
follicles,  sebaceous  and  sweat  glands)  which  have  been  displaced  and  car- 
ried into  the  tissues  by  some  penetrating  foreign  body  (Pels-Leusden). 
,  An  epithelial  cyst  is  represented  in  Fig.  405.  It  was  situated  in 
the  palm  of  the  hand  and  developed  six  months  after  a  gunshot  wound. 
A  small,  flattened,  lead  bullet  is  encapsulated  in  the  subcutaneous  tis- 
sues. The  capsule  does  not  sur- 
round the  foreign  body  closely,  be- 
ing separated  from  it  by  a  cheesy 
mass.     Upon  -one  side   a   piece   of 


Fig.  405. — Thaumatic  I'^pitiielial  Cyst  of 
THE  Palm  of  thk  Hand,  a,  Germinal 
cutaneous  tissue;  b,  bullet;  c,  cheesy  con- 
tents of  cyst ;  d,  connective-tissue  capsule 
with  epithelial  lining. 


Fig.  40G. — Traumatic  Epithelial  Cyst  of 
THE  Index  Finger. 


thickened  epidermis  (a),  which  was  carried  into  the  deeper  tissues  by 
the  bullet,  surrounds  it  like  a  hood.  This  epidermis  forms  part  of  the 
cyst  wall. 

Wiemann  hns  also  demonstrated  foreign  bodies  in  two  epithelial  cysts. 

Experimental  Production. — Similar  cysts  may  be  produced  experi- 
mentally. After  a  piece  of  skin  h;is  been  transplanted  into  the  sub- 
cutaneous tissues  or  into  the  abdominal  cavity  it  'becomes  enc^apsulated 
by  connective  tissue,  which,  however,  cannot  become  united  with  the 


FIBROEPITHELIAL  TUMORS  919 

epithelial  surface  of  the  transplanted  epidermis.  A  small  space,  which 
hecoiiu'S  tilled  and  distended  with  des(jnamated  epithelium,  remains  be- 
tween the  epithelium  and  connective  tissue,  and  the  walls  of  the  space 
become  lined  with  epithelium  formed  by  the  proliferation  of  the  epi- 
thelium of  the  transplanted  skin. 

The  treatment  consists  of  complete  extirpation. 

Literature. — Gnrrh.  Ueber  truumatischo  Epithelzyston  dor  Finger.  Beitr.  z. 
Idin.  Chir.,  Bd.  11,  1894,  p.  524.^ — Pels-Leusdcn.  Ueber  abnorme  Epithdisierung  und 
traumatische  Epithelzysten.  Deutsche  med.  Wochenschrift,  1905,  p.  1.578. — Wegner. 
Beitrag  zur  Lehre  von  den  traumatischen  Epithelzysten.  Deutsche  Zeitschr.  f.  Chir., 
Bd.  50,  1899,  p.  201. — Wiemann.  Epidermoide  (Epithelzysten)  unit  Einschluss  von 
Frenidkori)ern.  Zentralbl.  f.  Chir.,  1902,  p.  578. — Wurz.  Ueber  traumatische  Epithel- 
zysten.    Beitr.  z.  klin  Chir.,  Bd.  18,  1897,  p.  753. 

CHOLESTEATOMAS 

Cholesteatomas  are  tumors  which  are  closely  related  to  dermoids  and 
epidermoids.     Their  walls  are  alike,  but  their  contents  differ. 

Contents. — The  contents  of  these  tumors  consist  of  white,  pearllike, 
glistening  masses,  which  are  concentrically  arranged.  These  masses  are 
dry  and  upon  section  become  broken  up  into  fine  lamella?.  They  con- 
sist of  cornified,  firmly  compressed  epidermal  scales,  and  contain  large 
amounts  of  fatty  detritus  and  cholesterin;  for  this  reason  the  term 
cholesteatoma  has  been  applied  to  them.  The  walls  are  composed  of  a 
stratified  epithelium.  Transitional  stages  between  the  flattened  epithe- 
lium and  the  cornified  masses  may  be  seen  in  any  part  of  the  tumor. 
Sebaceous  and  sweat  glands  and  hair  are  but  rarely  found.  External 
to  the  epithelium  is  a  layer  of  loose  connective  tissue. 

Clinical  Course. — These  tumors  grow  slowly  without  producing  symp- 
toms for  a  long  time,  and  finally  may  become  as  large  as  a  hen's  egg 
or  larger.  If  the  wall  undergoes  necrosis  as  a  result  of  the  pressure  of 
the  contents,  the  latter  extend  along  the  spaces  of  the  surrounding  con- 
nective tissues.  Finally  even  bone  may  undergo  atrophy  following  pres- 
sure produced  by  these  masses. 

Most  Common  Sites  for  Development. — The  most  frequent  and  most 
important  situations  for  cholesteatomas  are  the  middle  ear,  the  pia  mater, 
and  the  urethra. 

They  develop  most  frequently  in  the  tympanum  and  the  antrum, 
varying  in  size  from  that  of  a  cherry  seed  to  that  of  a  hen's  egg.  They 
may  gradually  produce  a  pressure  atrophy  of  the  bone  and  give  rise  to 
dangerous  symptoms.  These  growths  almost  always  cause,  after  a  time, 
an  otitis  media  and  extend,  when  the  bone  is  perforated,  into  the  cranial 
cavity.  Some  of  these  tumors  develop  from  ectoderm  which  has  been 
displaced  into  the  mastoid  cells  or  the  tympanum  during  the  develop- 


920 


DIFFERENT    VARIETIES   OF   TUMORS 


inent  of  the  ear  (von  Mikulicz  and  Kiister),  and  some  follow  chronic 
inflammations,  the  squamous  epithelium  of  the  external  auditory  meatus 
growing-  through  the  perforation  of  the  membrana  tympani  to  replace 
the  cylindrical  epithelium  destroyed  by  suppuration.  The  secretion  of 
the  epithelium  then  becomes  inspissated  to  form  with  the  desquamated 
cells  the  cholesteatomatous  masses  (pseudocholesteatoma  of  von  Troltsch, 


Fig.  407. — Cholesteatoma  of  the  Sktjll  Bones,  which  has  Ixvaded  the  Orbit,  a, 
Part  of  tumor  which  has  invaded  the  orbit;  b,  external  table  elevated  by  tumor  mass; 
c,  layer  of  bone,  remains  of  external  table. 


Ilabermann,  Korncr).  It  is  possible  that  the  epithelium  of  the  middle 
ear  undergoes  a  metaplasia  in  some  cases,  for  eases  have  been  observed 
in  which  a  perforation  of  the  membrana  tympani,  permitting:  of  the 
ingrowth  of  squamous  epithelium,  could  be  positively  excluded  (Borst). 
In  chronic  inflanmiations  of  the  middle  ear  similar  masses  are  found 
(otitis  chronica  desquamativa),  but  the  epidermoidal  sac  is  wanting  in 
all  these  false  cholesteatomas  (Kiimmel). 

Cholesteatomas  of  the  pia  mater  appear  as  round  or  nodular  tumors, 
which  grow  very  slowly.  They  usually  occur  at  different  points  about 
the  base  of  the  brain ;  more  rarely  within  the  ventricles.  The  capsule 
of  the  tumor,  which  is  lined  by  a  number  of  layers  of  flattened  epi- 
tbcliiiiii,  is  fused  will)  llic  jiia  mater.     Bostrom  regards  these  tumors  as 


FIBROEPITHELIAL  TUMORS  921 

epidermoids,  and  liolieves  that  they  develop  from  germinal  ectodermal 
tissue  tlisplaced  into  the  anlage  of  the  pia  mater  about  the  fourth  or 
fifth  week  of  embrycmal  life.  Borst  and  others  regard  theiu  as  endo- 
theliomas. 

A  few  eases  of  cholesteatoma  of  the  l)()nes  of  tlie  face  and  skull 
have  been  observed.  They  have  been  found  in  the  frontal,  occipital, 
and  parietal  bones  (Blecher),  in  the  tempoi-al  bone,  the  pterygoid 
plates  of  the  sphenoid,  in  the  bones  of  the  orbit  (Lexer),  and  in  the 
mandible  (von  ]\likulicz),  appearing  as  slowly  growing  tumors  which 
gradually  destroyed  the  bone.  Not  infrO(iuently  these  tumors  are  epi- 
dural. Borchardt  has  removed  such  a  tumor  from  the  posterior  cranial 
fossa. 

Cholesteatomas  of  the  urinary  passages  are  not  true  tumors,  but  the 
products  of  degeneration  of  thit  epithelium,  the  occurrence  of  which  in 
these  passages  is  abnormal.  These  cornified  masses  occur  in  the  urethra, 
back  of  strictures,  in  the  bladder,  the  pelvis  of  the  kidney,  and  in  the 
ureter  ( Briichanow ) . 

Diagnosis. — A  positive  diagnosis  of  cholesteatoma  can  be  made  only 
when  the  characteristic  masses  are  discharged.  In  making  the  diagnosis 
the  symptoms  produced  by  the  pressure  of  the  tumor  should  also  be 
considered,  but  it  is  impossible  to  dilferentiate  cholesteatomas  from  other 
tumors,  unless  the  characteristic  masses  are  discharged. 

Treatment. — The  treatment  consists  of  removal  of  the  cornilied  masses, 
and,  in  the  true  cholesteatomas,  of  the  capsule  also. 

Literature. — Borchardt.  Cholesteatom  der  hinteren  Schadolgruhe.  Chir.-Kon- 
gress  Verhandl.,  1905,  II,  p.  49G. — Bostrotn.  Die  pialen  Epidermoide,  Dernioide  uiid 
Lipome  und  duralen  Dermoide.  Zentralbl.  f.  allg.  Path.,  Bd.  8,  1897,  p.  1. — Briich- 
anow. Ueber  einen  Fall  von  sog.  Cholesteatombikhmg  in  der  Harnblase.  Prag.  med. 
Wochenschr.,  Bd.  23,  1898,  p.  525. — Haug.  Ueber  das  Cholesteatom  der  Mittelohrniume. 
Zentralbl.  f.  allg.  Path.,  Bd.  6,  1895,  p.  12A.— II uberrnann  Zur  Entstehung  des  Chole- 
steatoms  des  Mittelohrs.  Arch.  f.  Ohrenheilkunde,  Bd.  27,  1889,  p.  42. — Ki'nnmel.  Die 
Verletzungen  und  chirurgischen  Erkrankungen  des  Ohrcs.  Handb.  d.  prakt.  C'hir.,  2. 
Aufl.,  Bd.  1,  p.  404. — Unferbcrger.  Ein  echtes  Cholesteatom  der  Schadelkiiochen. 
Deutsche  Zeitschr.  f.  Chir.,  Btl.  81,  1906,  p.  90. 

ADAMANTINOMAS   AND    FOLLICULAR    CYSTS    OF    THE    JAW 

Adamantinomas  are  benign  tumors  of  the  jaw  which  occasionally 
occur  in  young  people.  They  grow  very  slowly  and  may  l)ecome  as  lai'ge 
as  an  apple  or  a  fist.  These  tumors  usually  lie  encapsulated  within 
the  bone  and  gradually  expand  the  latter,  so  that  finally  the  tumor  is 
covered  only  by  a  shell  of  bone.  If  the  tumor  is  cystic,  a  "  parchment 
crackling  "  can  be  elicited  when  the  thin  shell  of  bone  covering  it  is 
palpated.  Adamantinomas  of  the  maxilla  may  grow  into  the  antrum 
of  Highmore  and  completely  fill  it. 
59 


922 


DIFFERENT   VARIETIES  OF   TUMORS 


Histology. — Upon  section  these  tumors  differ  very  much.  They  ap- 
pear either  as  homogeneous,  yellow,  resistant  masses,  the  consistency  of 
which  is  very  much  like  that  of  a  fibroma,  or  as  small  or  large  cysts 
(therefore  the  terms  "  Multilocular  cystomas  of  the  jaw,  epithelioma 
adamantinosum  cysticum  ").     The  entire  mass  may  be  enucleated  from 

the  expanded  bone,  unless  the  latter  has 
become  so  thinned  that  it  is  fractured  dur- 
ing the  enucleation  (Fig.  408), 


O^  23456 
23456 


Fig.   408. — Multilocular   Cystoma   of  the   Mandible    (Adamantinoma). 
a,  Condyle;  h,  symphysis. 


Microscopically  the  solid  tumors  consist  of  a  connective-tissue  stroma 
throughout  which  are  scattered  interlacing,  narrow,  and  wide  columns  of 
epithelial  cells.  If  these  are  abundant  the  tumor  is  very  similar,  histo- 
logically, to  a  carcinoma,  but  differs  from  a  carcinoma  in  that  it  is 
encapsulated.  Cylindrical  epithelial  cells  are  found  at  the  periphery  of 
these  colunms,  Avhile  the  cells  occupying  the  center  are  either  flat,  ar- 
ranged concentrically,  or  are  stellate  and  branched. 

If  the  epithelial  masses  undergo  regressive  changes,  small  cavities 
form  within  the  cell  columns,  which  later  enlarge.  The  cysts  are  usu- 
ally lined  with  but  a  single  layer  of  cylindrical  epithelium,  and  resemble, 
histologically,  cystadenomas.  The  histological  picture  is  still  different 
if  papillary  growths  develop  into  the  cavity  or  if  the  stroma  between 
the  columns  of  epithelial  cells  becomes  ossified. 

Origin  of  Adamantinomas. — Tlu>  form  and  arrangement  of  the  epi- 
thelium indicate  that  these  tumors  arise  fi-om  the  enamel  organ;  there- 
fore the  term  adamantinoma.  They  develop  from  the  remains  of  the 
epithelium  of  fhc  enamel  organ  (debris  paradentaires,  Malassez),  which 
lie  al)out  the  teeth  and  can  even  be  demonstrated  under  normal  condi- 
tions. Perhaps  the  hypera'mia  associated  with  inflammation  may  be  the 
exciting  cause  of  these  growths. 


FIBROEPITHELIAL  TUMORS 


923 


Diagnosis. — It  is  difficult  to  make  a  positive  diagnosis.  Siiiall,  solid 
tumors  may  be  mistaken  for  osteomas;  cystic  tumors  for  simple  cysts  of 
the  jaw,  or  if  it  is  not  known  that  the  tumor  has  existed  for  some  time, 
for  soft,  central  sarcomas. 

Treatment. — The  treatment  consists  of  free  exposure  of  the  tumor 
and  enucleation.  The  jaw  should  be  resected  in  order  to  prevent  recur- 
rence if  a  cystic  tumor  has  caused  a  pressure  necrosis  of  the  jaw  and 
rendered  it  fragile  (Fig.  408). 

Follicular  Cysts. — Follicular  cysts  of  the  jaw  are  simple  cysts  which 
develop  from  misplaced  or  supernumerary  tooth  buds.  The  position  of 
these  cysts  varies.  They  may  occur  upon  any  pai't  of  the  jaw  (e.  g.,  the 
ramus  of  the  lower  jaw,  in  the  orbit). 

They  are  found  chiefly  in  young  people.  When  they  occur  in  adults 
they  develop  about  the  wisdom  teeth  only,  and  most  frequently  in  the 
mandible.  They  grow  slowly,  without  causing  pain,  producing  a  local- 
ized expansion  of  the  bone.  They  are  found  more  rarely  in  the  maxilla, 
and  then  easily  extend  into  the  antrum. 

These  cysts  have  smooth  walls,  which  are  lined  by  an  epithelial  mem- 
brane derived  from  the  tooth  bud,  and  contain  a  rudimentary  or  fully 
developed  tooth.     The 


i  /^"^  «>  *  >. "!  '* 


fluid  contents  of  the  cyst 
are  seronuicous  in  char- 
acter and  rich  in  cho- 
lesterin. 

Follicular  cysts  are 
common,  and  the  diag- 
nosis is  not  so  difficult. 
But  it  should  be  remem- 
bered that  the  thinned 
and  expanded  cortical 
layer  of  bone  may  con- 
ceal a  central  sarcoma  or 
a  cystic  adamantinoma, 
and  that  the  antrum  of 
Highmore  may  be  dilated 
as  the  result  of  chronic 
inflammation. 

The  indications  for  treatment  are  to  remove  the  cortical  layer  of 
bone,  to  expose  the  cyst,  and  then  to  remove  the  cyst  wall. 

Periosteal  Cysts. — Periosteal  cysts  of  the  jaws  are  to  be  differentiated 
from  both  of  these  forms  of  true  cysts,  above  mentioned,  which  develop 
within  the  bone.  Periosteal  cysts  are  inflannnatory  growths.  They  fre- 
quently develop  after  a  periostitis  involving  the  root  of  the  tooth.    After 


Fig.  409. — Ad.\man tin<i.m.\. 


924  DIFFERENT   VARIETIES  OF   TUMORS 

the  destruction  of  the  hone  surrounding"  the  diseased  root,  a  cloudy, 
mucoid  fluid  containing  cholesterin  collects  beneath  the  periosteum  and 
produces  a  flat,  fluctuating  swelling  on  the  outer  surface  of  the  jaw, 
which  usually  is  situated  about  the  molar  or  bicuspid  teeth.  Such  a 
swelling  may  even  rupture  into  the  antrum  of  Highmore. 

It  is  questionable  whether  these  cysts  are  produced  by  inflammation 
alone.  The  finding  of  epithelium  in  the  walls  of  these  cysts  (Charcot, 
Malassez)  suggests  that  the  displacement  of  epithelium  has  something 
to  do  with  their  development.  It  may  be  that  displaced  epithelium  is 
essential  to  the  formation  of  the  cyst,  and  that  the  inflammation  acts 
as  the  exciting  cause. 

Periosteal  cysts  are  painful,  grow  quite  rapidly,  are  situated  just 
beijeath  the  periosteum,  and  occur  at  any  age.  When  these  facts  are 
taken  into  consideration,  periosteal  may  be  easily  difl'erentiated  from 
central  cysts. 

Free  incision  permitting  of  the  discharge  of  the  fluid,  curettage 
of  the  depressed  area  in  the  jaw,  with  removal  of  the  diseased  root, 
and  subsequent  tamponade,  are  followed  by  a  permanent  cure  after 
some  days. 

If  the  cyst  is  large  it  is  best  to  remove  a  large  piece  of  the  ex- 
ternal wall. 

Literature. — Becker.  Zur  Lehre  von  den  gutartigen  zentralen  Epithelialge- 
schwiilsten  der  Kieferknochen.  Arch.  f.  klin.  Chir.,  Bd.  47,  1894,  p.  52. — E.  Bennecke. 
Beitrag  zur  Kenntnis  der  zentralen  epithelialen  Kiefergeschwiilste.  Deutsche  Zeitschr. 
f.  Chir.,  Bd.  42,  1896,  p.  424. — Goebel.  Ueber  Kiefertumoren,  deren  Entstehung  auf 
das  Zahnsystem  zuriickrufiihren  ist.  Sammelreferat.  Zentralbl.  f.  Path.,  Bd.  8,  1897, 
p.  128. — Haasler.  Die  Histogenese  der  Kiefergeschwiilste.  Arch.  f.  klin.  Chir.,  Bd. 
53,  1896,  p.  749. — -Kruse.  Ueber  die  Entwicklung  zystischer  Geschwiilste  im  Unterkiefer. 
Virchow's  Arch.,  Bd.  124,  1891,  p.  137. — -Malassez.  Sur  le  role  des  debris  epitheliaux 
paradentaires.  Arch,  de  physiol.,  1885. — Nasse.  Paradentares  zentrales.  Adeno- 
kystom  des  Unterkiefers.     Chir.-Kongr.  Verhandl.,  1890,  I,  p.  129. 

EPITHELIAL   CYSTS   DEVELOPING   FROM   NORMAL   EMBRYONAL   ANLAGE 

Cysts  may  develop  from  persisting,  noninvoluted  remains  of  dift'er- 
ent  embryonal  fissures  and  canals  of  ectodermal  and  entodermal  origin. 
The  most  im])()r'tant  of  these  cysts  occur  in  the  neck,  the  floor  of  the 
mouth,  and  in  the  abdomen,  the  last  developing  from  the  uraehus  and 
the  vitelline  duct. 

Branchial  Cysts. — The  epithelial  cysts  occurring  in  the  neck  are 
divided,  dei)en(ling  upon  their  position  and  origin,  into  the  lateral  and 
medinn  ;  llic  I'oniier  dev('l()i)ijig  from  the  braneliiiil  clefts,  the  latter  from 
the  thyre(»gl(»,ss;il  duel.  'I'liese  cysts  ai'e  closely  related  genetically  to  the 
latenil  and  median  cervic^d  fistuhe. 

Branchial  cysts  usually  develop  in  the  young.     They  may  even  be 


FIBROEPITHELIAL  TUMORS  925 

congenital.  Thoy  form  i)ainl('ss  swellings,  which  grow  slowly.  Often 
the  beginning  of  the  enJai'genient  is  not  noted.  They  develop  in  the 
region  between  the  jaw,  the  inner  border  of  the  sterno-cleido-niastoid 
muscle,  and  the  h^-oid  bone.  Externally  they  are  covered  by  the  pla- 
tysma.  They  extend  inward  to  the  digastric  nuiscle.  Tluy"  may  become 
larger  than  a  fist,  and  then  they  extend  downward  almost  to  the  clavicle 
and  backward  beneath  the  sterno-cleido-mastoid  muscle  into  the  poste- 
rior triangle  of  the  neck.  The  swelling  produced  by  such  a  cj'st  is 
flat  or  hemispherical,  has  fairly  well-defined  boundaries,  a  smooth  sur- 
face, and,  depending  upon  the  character  of  the  contents,  a  doughy  or 
fluctuating  consistency.  The  skin  covering  it  is  normal  and  can  be 
raised  from  it,  but  the  tumor  proper  can  be  displaced  but  little,  as  it 
is  adherent  to  the  deeper  tissues.  The  firm,  smooth  wall  of  the  cyst 
has  either  a  white  lining  like  that  of  a  dermoid,  or  a  grayish  red  lining, 
which  is  often  very  granular,  resembling  nuicous  membrane.  The  con- 
tents are  cheesy,  mucoid,  or  serous,  with  a  number  of  transitional 
forms.  The  symptoms  are  entirely  dependent  upon  the  size  and  posi- 
tion of  the  cyst. 

Branchial  cysts  usually  develop  from  remains  of  the  second  bran- 
chial cleft;  exceptionally,  from  the  first  or  third  (Fritz  Kiinig).  Genet- 
ically they  are  closely  related  to  congenital  branchial  fistula?,  the  in- 
ternal orifice  of  which  usually  communicates  with  the  supratonsillar 
fossa,  when  the  fistula  is  complete;  the  external  orifice  emptying  upon 
the  skin  anterior  to  the  sterno-cleido-mastoid  nuLscle  at  any  level  of 
the  neck. 

The  epithelial  lining  of  these  cysts,  like  that  of  the  fistuhe,  differs 
in  character.  The  inner  part  of  branchial  fistula?  is  of  entodermal 
origin  and  is  lined  either  with  ciliated  epithelium  or  with  squamous 
epithelium  provided  with  lymphadenoid  tissue  or  follicles  (like  pha- 
ryngeal mucous  membrane),  while  the  outer  part  is  derived  from  ecto- 
derm, and  is  lined  with  squamous  epithelium  containing  papilla?,  and 
often  glands  of  the  skin.  There  are  branchial  fistulce,  however,  which 
are  lined  throughout  with  cylindrical  epithelium,  having  developed  en- 
tirely from  the  entodermal  portion  of  the  cleft. 

The  lining  and  contents  of  branchial  cysts  differ,  depending  upon 
whether  the  epithelium  from  which  the  cysts  develop  is  derived  from 
the  entodermal  or  ectodermal  portion  of  the  cleft.  Cysts  lined  with 
skin  or  epidermis  have  cheesy  contents,  like  a  dermoid,  and  do  not 
differ  from  dermoids  or  epidermoids  (p.  916)  of  a  doughy  consistency. 
Cysts  derived  from  the  entoderm  have  seronmcous  contents  and  fluc- 
tuate distinctly.  The  inner  surface  of  these  cysts  often  resembles  closely 
a  granular  tuberculous  membrane,  but  the  granulations  are  firm  and 
cannot  be  wiped  away  as  in  the  tuberculous  membrane,  for  they  are 


926  DIFFERENT   VARIETIES  OF   TUMORS 

produced  by  iiiiinerous  lyiiii)liati('  follicles  situated  just  ])eneath  the  mu- 
cous uienibrane.  Occasionally,  ditt'ercnt  fonns  of  epithelium  are  found 
in  different  parts  of  the  cyst,  or  if  the  cysts  are  multilocular,  the 
smaller  compartments  may  be  lined  by  dift'erent  kinds  of  epithelium. 
The  outer  layers  of  the  wall  of  the  cyst  may,  like  those  of  a  branchial 
fistula,  contain  lymphadenoid  tissue,  striated  muscle  fibers,  or  cartilage 
(vide  Plate  II). 

Thyreoglossal  Cysts. — Cysts  developing  from  remains  of  the  thyreo- 
glossal  duct  never  become  as  large  as  branchial  cysts.  They  lie  in  the 
median  line  of  the  neck  in  front  of  the  hyoid  bone,  between  it  and 
the  larynx,  or  below  the  larynx  in  the  region  of  the  jugulum.  They 
form  round,  sharply  defined,  fluctuating  tumors,  which  may  be  easily 
displaced,  and  are  covered  by  normal  skin.  Although  they  are  freely 
movable,  it  can  always  be  noted  upon  palpation  that  they  are  attached 
to  the  deeper  tissues,  and  often  the  cordlike  attachment  can  be  traced 
to  the  hyoid  bone.  This  cord,  which  may  so  often  be  palpated,  is 
the  remains  of  the  thyreoglossal  duct.  If  the  duct  remains  patent 
and  ruj)tures  upon  the  surface  of  the .  neck,  a  median  cervical  fistula 
forms. 

The  lining  of  the  cysts  and  fistuloe  developing  from  remains  of  the 
thyreoglossal  duct  dift'er.  If  they  develop  from  the  lower  part  of  the 
duct  they  will  be  lined  with  ciliated  epithelium ;  if  from  the  upper 
part  (ductus  lingualis),  with  mucous  membrane  like  that  of  the  mouth. 
The  walls  of  the  cysts  may  contain  mucous  follicles. 

Some  of  the  difficulties  in  making  a  diagnosis  of  branchial  cysts 
have  already  been  mentioned  in  discussing  dermoids.  The  large,  dis- 
tinctly fluctuating  cysts  may  resemble  congenital,  cystic  lymphangiomas 
so  closely  that  a  definite  diagnosis  can  be  made  only  by  microscopic 
examination.  In  median  cysts  the  cord,  which  may  often  be  palpated 
and  extends  to  the  hyoid  bone,  is  of  great  diagnostic  significance.  Der- 
moid cysts  are  superficial  and  freely  movable.  Tuberculous  abscesses 
are  usually  associated  with  enlargement  of  the  neighboring  lymph  nodes. 
Branchial  cysts  may  be  most  easily  confused  with  small,  non-lobulated 
lipomas  occurring  in  front  of  the  hyoid  bone. 

The  ductus  lingualis,  a  part  of  the  thyreoglossal  duct  extending 
from  tlie  foramen  caecum  to  the  hyoid  bone,  has  a  genetic  relationship 
to  small  cysts  occurring  about  the  foramen  caecum  and  cysts,  known  as 
ranula,  which  develop  in  the  floor  of  the  mouth.  Some  ranuhie  are  lined 
with  ciliated  epithelium  and  develop  from  Bochdalek's  tubules,  which 
ar(>  evajii nations  of  the  ductus  lingualis. 

Cysts  of  the  TJrachus. — Cysts  of  the  urachus,  which  are  not  frequent, 
develop  iidin  1lie  embryonal  canal  connecting  the  bladder  with  the 
allantois.     The  urachus  usually  undergoes  complete  involution  and  be- 


IM.ATE    J I 


\^:?^^'-^v; 


V '  .'   HaS" 


c 


Lateral  r>Ko.\(iiiAr.  Fistula. 

(a)  Heiniiant?  of  ciliated  epitlu'liiiin. 

(b)  Lymph  follicle. 

(c)  Loiiiiiludiiial  musculature  of  the  fistula. 


FlJiROEl'lTIlELlAJ.  TUMORS  927 

comes  closed  to  form  the  superior  tnu;  ligament  of  the  bladder.  If  the 
canal  remains  open,  a  urachal  fistula  is  formed,  from  wliir-li  urine  is 
discharged.  If  the  canal  becomes  only  partially  closed,  small  cysts, 
the  size  of  a  bean,  or  a  very  large  cyst  which  contains  yellowish  fluid, 
develops. 

Cysts  of  the  Vitelline  Duct. — Cysts  may  also  develop  from  the  vitel- 
line duct,  which  up  to  the  eighth  week  of  embryonal  life  extends  be- 
tween the  intestines  and  the  yolk  sac.  Vitelline  cysts,  like  cysts  of  the 
urachus,  are  rare.  If  the  duct  remains  patent,  a  congenital  fistula, 
from  which  mucus  and  intestinal  contents  are  discharged,  persists  after 
the  cord  separates.  If  the  umbilical  end  of  the  duct  closes  and  the 
intestinal  end  remains  open,  a  blind  sac  (Meckel's  diverticulum),  which 
empties  into  the  ileum,  persists.  If  the  intestinal  end  closes,  and  the 
umbilical  end,  from  Avhich  the  nnicous  membrane  protrudes,  remains 
open,  an  und)ilico-vitelline  diverticulum  is  formed.  If  both  extremi- 
ties become  closed^  but  the  intermediate  part  of  the  duct  renuiins  patent, 
a  vitelline  cyst  ( enteroc.ystoma )  forms  as  the  secretion  is  poured  out. 
The  walls  of  the  cysts,  like  those  of  the  fistula^  and  diverticula,  are 
composed  of  regularly  and  irregularly  arranged  bundles  of  smooth  mus- 
cle fillers.  They  are  lined  with  epithelium  which  corresponds  histo- 
logically to  either  the  adult  or  embryonal  types  of  intestinal  epithelium. 
These  cysts  are  foiuid  within  the  abdominal  wall  at  the  level  of  the 
umbilicus,  and  in  front  of  the  peritoneum,  or  within  the  abdominal 
cavity.  When  they  occur  within  the  abdonnnal  cavity  they  are  some- 
times adherent  to  the  parietal  peritoneum ;  at  other  times  to  intestinal 
loops  or  are  situated  within  the  mesentery.  The  occasional  occurrence 
of  nuiltiple  cystomas  suggests  that  some  of  these  tumors  may  develop 
from  displaced  portions  of  germinal  tissue,  which  later  forms  the  in- 
testines (Borst). 

In  the  treatment  of  congenital  epithelial  cysts  the  cyst  wall  should 
be  completely  enucleated.  This  may  be  difficult,  as  the  cyst  nmy  have 
contracted  adhesions  with  the  surrounding  tissues  at  diffci-cnt  points. 

Literature. — Hildebrand.  1.  Ueber  angeborene  epitheliale  Zystcn  imd  Fisteln 
des  liaises.  2.  Ueber  angeborene  zystische  Geschwiilstc  der  Steissgegend.  Ardi.  f. 
klin.  Chir.,  Bd.  49,  1895,  p.  167. — Fr.  Konig.  ITeher  Fistula  colli  congenita.  Arch, 
f.  klin.  Chir.,  Bd.  51,  1896,  p.  578. — Lexer.  Ueber  die  Behandlung  der  ITrachusfistel. 
Arch.  f.  klin.  Chir.,  Bd.  57,  1898,  p.  73; — Magenschleimhaut  im  persistierenden  Dottor- 
gang.  Arch.  f.  klin.  Chir.,  Bd.  59,  1899,  p.  859. — -Nasse.  Ein  Fall  von  Knterokystom. 
Arch.  f.  klin.  Chir.,  Bd.  45,  189.'^,  p.  700. — v.  Recklinghaxisen.  Urachuszyste.  Deutsche 
med.  Wochenschr.,  1902,  No.  34,  Vereinsbeilage,  ]).  266. — Roth.  Ueber  Missbildungen 
im  Bereich  des  Ductus  omphalo-mesentericus.  Virchows  Arch.,  Bd.  86,  1881,  p.  371. — 
Sultan.  Zur  Kenntnis  der  Halszysten  und  -fisteln.  Deutsche  Zeitschr.  f.  Chir.,  Bd. 
48,  1898,  p.  113. 


928  DIFFERENT    VARIETIES   OF   TUMORS 

CHAPTER    II 

CARCINOMAS 

Malignant  epithelial  neAv  growths  are  grouped  under  the  term  car- 
cinoma or  cancer.  They  are  characterized  hy  an  infiltrating  growth, 
destroying  the  tissues  which  are  invaded. 

Relation  Between  Parenchyma  and  Stroma. — The  relation  between  the 
parenchyma  and  stroma  varies  in  different  tumors  and  in  different  fields 
of  the  same  tumor:  The  epithelial  cells  composing  the  parenchyma  differ 
morphologically  and  in  their  arrangement,  depending  upon  whether  they 
have  developed  from  the  skin,  mucous  membranes,  glandular  viscera, 
embryonal  epithelial  rests,  from  preexisting  fibroepithelial  tumors,  or 
from  epithelial  cysts.  In  spite  of  the  rapid  multiplication  of  the  cells 
in  a  carcinoma,  they  preserve  the  characteristics  of  the  parent  cells; 
for  example,  the  cells  of  a  carcincma  arising  in  skin  become  cornified; 
the  cells  composing  carcinomas  arising;  in  the  ga-strointestinal  tract, 
liver,  and  thyroid  gland  secrete  mucus,  bile,  and  colloid  respectively. 
The  stroma,  or  connective-tissue  framew^orkj  consists  of  netlike  tra- 
becular varying  in  thickness  and  firnmess.  The  stroma  consists  partly 
of  newly  formed  connective  tissue,  partly  of  the  tissues  which  have 
been  invaded.  It  may  therefore  contain,  besides  old  connective  tissue, 
muscle,  the  ])aronchyma  of  the  viscera  involved,  bone,  etc. 

Scirrhus  and  Medullary  Forms. — If  the  stroma  predominates  the  car- 
cinoma is  hard  and  resistant  and  tends  to  undergo  cicatricial  contrac- 
tion. If  the  parenchyma  predominates  over  the  stroma  the  tumor  is 
soft.  The  first  form,  Avhich  is  called  scirrlius,  never  becomes  as  large  as 
the  latter,  which  is  called  a  mediilldru  carcinoma.  The  intermediate 
form  is  usually  called  the  carcinoma  simplex. 

Clinical  Appearance. — A  carcinoma  nuiy  appear  in  a  number  of  dif- 
ferent forms,  which  depend  moi-e  \\])ou  the  tissues  in  which  tlic  car- 
cinoma originates  than  upon  the  arrangement  of  the  cells  composing 
it ;  for  example,  carcinomas  developing  within  the  viscera  are  usually 
nodular,  while  those  develo])ing  in  the  skin  or  mucous  membranes  tend 
to  form  tuberculated,  caulitiowerlike,  papillary,  or  polypoid  growths, 
associated  with  a  flat  infiltration  of  the  surrounding  tissues  and  the 
formation  of  deep,  craterlike  ulcers. 

Histogenesis. — There  is  no  single  conception  among  autliorities  con- 
c<'i-nin'j  I  he  histogenesis  of  carcinoma.  After  Virchow's  teaching  con- 
(•(•r'tiiiii;  llic  coimective-tissue  origin  of  carcinoma  had  been  disproven 
hy  the  hfilliant  researches  of  Thicr-sch,  Waldcyer,  Tlauser,  and  others, 
l\<)stci'  (jrmonstrated  that  some  of  tlie  tumors  regarded  as  carcinoir)as 


CARCINOMAS  929 

developed  from  tlie  endotlieliuni  of  blood  vessels,  and  Avere,  therefore, 
really  of  a  connective-tissue  nature.  For  this  reason  tliese  tumors 
have  been  separated  from  carcinomas,  sometimes  being  classified  with 
sarcomas,  at  other  times  being  regarded  as  a  separate  group  {endo- 
thcUomas).  Kibbert  has  ascribed  to  the  connective  tissue  a  very  signifi- 
cant role  in  the  development  of  carcinomas.  According  to  him,  the 
proliferation  of  the  connective  tissues  is  the  caiLse,  Avliieh  leads  to  the 
irregular,  atypical  proliferation  of  the  epithelial  cells  and  the  invasion 
of  the  tissues. 

Squamous-cell  Carcinoma. — It  is  the  generally  accepted  view  that  in 
a  squamous-cell  carcinoma  the  proliferation  begins  in  the  germinal  layer 
of  the  epidermis.  At  the  point  at  which  the  carcinoma  develops  the 
cells  multiply  rapidly,  preserving  their  embryonal  characteristics  and 
possessing  irregular — the  so-called  pathological — karyokinetic  figures, 
which  may  be  easily  explained  upon  the  basis  of  excessive  growth. 
The  proliferating  cells  extend  in  all  directions,  raising  and  casting 
otf  the  normal  cells  and  sending  down  conelike  processes  into  the 
deeper  tissues  and  toward  all  sides,  piercing  the  basement  membrane, 
which  normally  separates  the  epithelial  cells  from  the  underlying  struc- 
tures. By  the  continued  budding  of  these  conelike  processes,  which 
are  usually  solid,  a  number  of  new  processes  are  sent  out  into  the  tis- 
sues, so  that  eventually  the  point  at  which  the  carcinoma  develops  and 
its  numerous  processes  resemble  the  roots  of  a  plant.  Naturally  in 
microscopical  sections  the  columns  of  cells  which  have  been  cut  trans- 
versely or  obliquely  appear  as  separate  islands  of  epithelium  or  as  alve- 
oli. True  alveolar  formation  occurs  if  a  group  of  cells  becomes  con- 
stricted off  from  the  epithelial  process;  but  this  is  rare,  as  usually  the 
groups  of  cells  which  appear  as  separate  would  be  found  to  be  connected 
\\'\\\\  the  large  epithelial  downgrowths  if  serial  sections  were  made. 

llauser  and  Petersen  have  succeeded  in  demonstrating  clearly  the 
method  of  growth  by  means  of  reconstruction  in  wax,  using  Born's 
method,  which  has  been  employed  so  extensively  in  reconstructing  em- 
bryos. They  have  shown  by  this  method  that  growth  begins  sinuil- 
taneously  at  a  number  of  points  closely  adjacent  to  each  other. 

According  to  the  opinions  of  many  authorities  the  cells  of  glands — 
for  example,  in  carcinonuis  of  the  skin — the  cells  of  the  hair  follicles, 
and  of  the  sebaceous  glands,  and  perhaps  even  of  the  sweat  glands  are 
involved  in  the  growth  (Borst).  According  to  Eibbert,  these  observa- 
tions are  incorrect,  the  histological  picture  having  been  wrongly  inter- 
preted, as  the  epithelial  cells  surround  the  glands  and  appear  to  de- 
velop from  them,  while  in  reality  they  do  not. 

Changes  in  Connective  Tissue. — While  the  proliferating  epithelial 
cells  are  invading  the  cutis  and  subcutaneous  tissues,  and  are  produc- 


930  DIFFERENT   VARIETIES   OF   TUMORS 

ing  a  pressure  atrophy  of  the  normal  tissues,  the  connective  tissues  do 
not  remain  inactive.  Proliferative  changes  occur  in  the  connective  tis- 
sues, similar  to  those  in  mikl  inflanniiation,  which  lead  to  the  foi-mation 
of  a  fibriUar  connective  tissue  rich  in  bh)ud  vessels.  Atrophy  and  pro- 
liferation occur  about  tlie  invading  epithelial  processes,  which  become 
surrounded  with  remains  of  the  tissues  that  have  been  invaded  and  by 
those  newly  formed.  When  a  carcinoma  invades  the  skin,  mucous  mem- 
brane, or  viscus,  the  preexisting  stroma  forms  part  of  the  stroma  of 
the  tumor,  while  the  stroma  of  the  part  of  the  tumor  which  develops 
above  the  surface  of  the  skin,  mucous  membrane,  or  viscus  is  always 
newly  formed. 

A  reactive  proliferation  occurs  in  all  tissues  invaded  by  carcinoma 
(especially  in  bone),  as  is  demonstrated  by  the  study  of  metastases. 

According  to  Hauser,  the  growth  relations  in  carcinomas  composed 
of  cylindrical  cells,  which  may  develop  from  any  mucous  membrane  or 
embryonal  rest  composed  of  cylindrical  cells,  are  the  same  as  those  de- 
scribed above  in  squamous-cell  carcinoma.  In  cylindrical-cell  carcinoma 
the  epithelial  processes  are  not  solid,  but  are  provided  with  a  lumen 
and  resemble,  histologically,  a  gland. 

Carcinomas  developing  from  glandular  epithelium  grow  in  nnich  the 
same  way  as  described  in  the  preceding  paragraph.  Sometimes  the  epi- 
thelial downgrowths  have  a  lumen,  at  other  times  they  do  not.  Tlie 
normal  glands  are  surrounded  and  compressed  by  the  carcinonuitous 
tissue,  which  spreads  out  in  all  directions. 

The  view  generally  accepted  at  the  present  time  concerning  the  de- 
velopment of  carcinoma  is  especially  combated  by  Eibbert.  According 
to  him,  carcinomas  develop  because  of  the  weakness  of  the  tissues  in 
proximity  to  the  cells,  which  are  then  no  longer  able  to  offer  resistance 
to  the  downgrowth  of  proliferating  epithelium,  as  they  normally  do. 
As  a  result  of  this  weakness  of  the  subepithelial  connective  tissues  the 
cells  break  through  the  basement  membrane  and  invade  the  surrounding 
tissues. 

Borst  admits  that  not  infrequently  groups  of  epithelial  cells  become 
separated  or  displaced  as  a  result  of  the  inflammatory  proliferation  of 
connective  tissues,  and  that  the  epithelium  may  develop,  but  in  his  opin- 
ion the  initiative  to  the  proliferative  processes  lies  in  the  epithelium. 
This  is  the  opinion  of  the  majority  of  pathologists  at  the  present  time. 

Mode  of  Growth. — There  is  considerable  difference  of  opinion  among 
aiillioi'ities  as  to  the  way  in  which  carcinomas  grow.  Ribbert,  Borst,  and 
others  believe  that  a  carcinoma  begins  in  small,  limited,  ejuthelial  area, 
and  that  the  cells  of  this  area  proliferate  and  invad(>  the  surrounding 
normal  cpilliclial  and  glandnlai-  tissue,  which  are  thus  destroyed,  while 
Ilanser,    Px'nckc,  and  others  think  that  th(>  normal  colls  bounding  the 


CARCINOMAS  <J31 

area  in  which  the  carcinoma  develops  become  transformed  into  carci- 
noma cells  and  that  the  tumor  eidarjies  by  peripheral  a])position.  'I'his 
theory  of  the  transformation  of  normal  epithelium  into  earcinomaUtus 
tissue  is  based  upon  the  microscopic  changes  in  the  surface  and  glan- 
dular epithelium  found  at  the  margin  of  the  carcinoma.  It  is  sup- 
posed that  there  is  an  irritation  originating  at  the  point  primarily 
involved  which  effects  this  transformation  of  normal  into  carcinoma 
cells.  According  to  Ribbert's  investigation,  the  proliferation  occurring 
in  the  epithelial  cells  at  the  margin  of  a  carcinoma  is  to  be  regarded 
as  a  reactive  inflammation  similar  to  that  occurring  in  connective  tis- 
sues which  have  been  invaded  by  carcinoma  cells,  and  not  as  a  trans- 
fornuition  of  normal  epithelial  cells  into  carcinoma  cells. 

The  same  type  of  epithelial  proliferation,  even  atypical,  may  occa- 
sionally be  demonstrated  in  different,  chronic  inflannnatory  processes. 
This  type  is  found,  especially  in  tuberculosis  of  the  skin  (Friedlaender), 
without  indicating  a  carcinomatous  degeneration,  or  changes  which  lead 
to  carcinoma  formation.  It  should  also  be  remembered  that  groups 
of  carcinoma  cells  may  invade  the  surface  epithelium  and  surround  the 
normal  gland  tubules,  so  that  normal  glandular  alveoli  may  be  confused 
with  the  newly  formed  alveoli  found  in  carcinomas. 

Infiltrating  Growth.— Carcinomas  have  almost  exclusively  an  infil- 
trating growth.  Carcinomas  of  the  skin  and  mucous  membranes  extend 
along  the  surface  and  invade  the  deep  tissues,  and  may  proliferate  to 
form  growths  which  extend  above  the  surface  of  the  skin  or  mucous 
membrane.  If  the  carcinoma  develops  in  a  viseus,  the  new  growth 
extends  in  all  directions.  The  carcinoma  cells,  as  the  tumor  enlarges, 
displace  the  tissues  and  invade  the  delicate  lymphatic  spac(»  ami  vessels. 
In  this  way  the  door  is  opened  for  the  formation  of  early  and  extensive 
metastases. 

Lymphatic  Metastases. — The  carcinoma  cells,  after  having  invaded 
the  lymphatics,  may  be  detached  by  the  lymph  stream  and  carried  into 
the  tissues  surrounding  the  primary  focus,  or  they  may  invade  the  latter 
by  means  of  their  own  auueboid  movements.  When  the  cells  invade 
the  surrounding  tissues,  small,  red,  fii'm  nodules  which  nevei'  become 
larger  than  a  pea  develop  in  a  wide  area  surrounding  the  primary  focus. 
The  development  of  these  small  nodules  in  the  skin  is  often  associated 
with  carcinoma  of  the  breast — the  so-called  lenticular  carcinoma.  This 
process  is  called  the  local  formaiion  of  metastases  or  the  dissemination 
of  the  carcinoma  into  the  surrounding  tissue.  The  growth  extends  in 
all  directions  along  the  lymphatic  vessels,  and  th(>  cutis  sui-rounding  a 
new  growth  may  become  almost  symmetrically  infiltrated.  Often  the 
boundaries  of  such  an  infilti'ated  area  are  sharply  defined  and  scalloped 
and   the   area  is   reddened.      The   clinical    picture  then   resembles  very 


932  DIFFERENT   VARIETIES   OF   TUMORS 

closely  that  of  erysipelas.  [Occasionally  in  carcinoiiiii  of  the  shin  or 
breast,  reddened,  indurated  lines  are  seen  running  out  from  the  priinary 
focus.  If  the  primary  lesion  is  ulcerated  it  is  frequently  difficult  to 
decide  whether  the  lymphangitis  is  of  a  carcinomatous  or  bacterial 
origin.  If  of  bacterial  origin,  it  will  usually  subside  after  the  applica- 
tion of  an  alcohol  compress  or  moist  dressing.  It  is  important  to  deter- 
mine the  nature  of  the  process  as  the  indication  concerning  the  extent 
of  the  proposed  operation,  and  the  prognosis  depend  upon  the  nature 
of  the  lymphangitis.] 

Frequently  the  carcinoma  cells  are  can-ied  into  the  adjacent  lymph 
nodes  without  becoming  attached  to  the  walls  of  the  lymphatic  vessels. 
[It  should  be  remembered  in  this  connection  that  any  trauma  of  the 
endothelium  of  the  lymphatics  favors  the  attachment  of  carcinoma  cells 
in  the  lymphatic  vessels  and  the  development  of  nodules.  Extensive 
formation  of  secondary  nodules  in  the  lymphatic  vessels  is  frequently 
observed  in  carcinoma  of  the  breast  after  an  osteopath  or  masseur  has 
attempted  to  massage  away  the  tumor.] 

In  the  majority  of  cases  of  carcinoma  metastases  develop  early  in 
the  regional  lymph  nodes.     The  cells  are  first  carried  into  the  cortical 

sinus,  then  into  the  follicles, 
and  are  finally  deposited  in 
the  medullary  portion  of  the 
nodes.  The  nodes  soon  become 
filled  with  the  rapidly  mul- 
tiplying carcinoma  cells,  and 
the  lymphoid  tissue  is  com- 
pressed and  destroyed.  The 
lymph  nodes  when  involved 
-*^'"'  become     indurated     and     en- 

FiG    410.  — Metastatic   Foci    ix    iin:   Axh.i.ary       larged.        The      induration      is 
liYMi'H  Nodes  Secondary  to  a  Carcinoma  op  .  .  .         r* 

THE  liREAST.  quitc  charactcristic  and  is  of 

great  diagnostic  significance. 
Upon  section  of  small  lymph  nodes  but  recently  involved,  yellow  or 
white  foci  which  fuse  with  each  other  may  be  seen  within  a  grayish 
red  tissue.  When  the  lymph  nodes  have  been  involved  for  some  time 
they  become  transformed  into  carcinomatous  masses. 

The  carcinoma  cells  later  break  thr-ough  the  capsule  of  the  lymph 
nodes,  and  adjacent  nodes  become  fused  to  form  large  nodular  tumors. 
The  surrounding  loose  connective  tissues  then  become  invaded.  If  the 
skin  covering  a  carcinoma  becxmies  infiltrated,  it  finally  ulcerates,  and  a 
nodular  iiinss,  the  center  of  which  degenerates  to  form  a  craterlike,  foul- 
smelling  ulcci-,  projects  above  the  surface  of  th(;  sHdn.  The  extension 
of  the  carcinoma  cells  along  the  perivascular  ]ymi)hatics  of  large  ves- 


CARCINOMAS 


933 


sels  is  dangerous,  as  severe,  nsually  fatal,  haemorrhage  follows  the  inva- 
sion of  the  different  coats  of  the  arteries  and  thrombosis  and  dissemina- 
tion of  the  growth  through  the  blood  stream  follow  the  invasion  of  the 
walls  of  the  vein. 

Involvement  of  lymph  nodes  which  ordinarily  do  not  receive  lymph 
from  the  area  involved,  but  are  out  of  the  path  usually  traveled  by 
the    lymph,    has    been    ex- 
plained  by  retrograde  em- 
bolism. 

It  is  more  probable  in 
these  cases  that  the  car- 
cinoma cells  proliferate 
along  the  lumina  of  the  ves- 
sels, forming  a  continuoiLs 
mass,  than  that  the  lymph 
stream  becomes  reversed  as 
the  resiilt  of  the  occlusion 
of  one  of  the  larger  lym- 
phatics and  that  the  cells 
are  carried  to  the  nodes  by 
the  lymph.  As  the  result  of 
this  carcinomatous  prolif- 
eration along  the  lumina  of 
the  lymphatic  vessels,  white 
cords  are  formed  in  carci- 
noma   of    the    peritoneum 

Avhich  may  frequently  be  seen  extending  from  one  diseased  lymph 
node  to  another  beneath  the  membrane.  The  white  cords  correspond  to 
lymphatic  vessels  filled  with  carcinoma  cells.  White,  netlike  cords  may 
also  be  seen  beneath  the  visceral  pleura,  associated  with  metastatic  foci 
in  the  lymph  nodes  or  lungs. 

Hsematogenous  Metastases. — Ilfematogenous  metastases  may  follow  in- 
volvement of  the  lymphatics,  occurring  when  carcinoma  cells  invade  the 
thoracic  duct  or  are  carried  by  the  lymph  stream  into  the  veins. 

Direct  hematogenous  metastases,  occurring  earlier  than  the  sec- 
ondary above  described,  are  rare  but  more  dangerous.  They  follow 
the  invasion  of  the  walls  of  veins,  emboli  of  carcinoma  cells  being  car- 
ried into  the  general  circulation.  Direct  htrmatogenous  metastases  may 
develop  from  carcinomatous  lymph  nodes  as  well  as  from  the  prinuiry 
focus. 

The  lungs  and  liver  are  the  first  filters  of  the  systemic  and  portal 
circulations  respectively.  The  one  or  the  other,  depending  upon  the 
position  of  the  primary  tumor,  is  first  involved  in  ha?matogenous  metas- 


FiG.  411. — Carcinomatous  Lymph  Node.s.  a.  He- 
mains  of  lymplioid  tissue;  h,  groups  of  carcinoma 
cells. 


934 


DIFFERENT    VARIETIES   OF   TUMORS 


tases.     If  the  carcinoma  cells  are  carried  from  these  organs,  they  are 
deposited  in  the  different  viscera,  the  skin,  and  bones. 

It  is  worth.y  of  note  that  all  carcinomas  do  not  have  the  same  tend- 
ency to  the  formation  of  metastases  in  bone.  This  tendency  is  most 
pronounced  in  carcinomas  of  the  breast,  prostate  and  thyroid  gland,  and 
in  hypernephromas.  The  metastases  usually  develop  in  the  ends  of  long, 
hollow  bones  or  in  the  bodies  of  the  vertebra,  which  even  in  adults  are 


Fig.  412. — Scikuhu.s  of  tuk  Brka.st  with  Skcondauy  Xodules  in  the  Skin. 


richly  snpplicd  with  blood  vessels.  The  bone,  at  the  point  at  which  the 
metastasis  develops,  either  undergoes  an  atrophy  resulting  in  a  spon- 
taneous fracture,  or,  when  the  vertebras  are  involved,  in  a  gibbus,  or  it 
is  stimulated  to  the  formation  of  considerable  new  bone  (osteoplastic 
carcinoma). 

In  carcinomas,  metastases  usually  develop  by  way  of  the  lymphatics, 
while  in  sai'comas  metastases  usually  develoj)  by  way  of  the  blood 
stream.  This  difference  depends  upon  the  peculiai'ities  of  growtli  of 
these  two  chisses  of  tumors;  perhaps  also  upon  the~fact  that  carcinoma 
cells  may  die  in  the  blood  stream. 


CARCINOMAS  935 

Histology  of  Metastatic  Growths. — The  cells  found  in  the  metastases 
preserve  the  cliMraeteristics  of  those  composing  the  primary  growth. 
They  may,  however,  lose  their  typical  arrangement  and  their  properties 
of  forming  keratin  or  mncns  in  the  metastases,  these  changes  sometimes 
being  indicative  of  very  rapid  proliferation,  at  other  times  of  degen- 
eration. 

Implantation  Carcinoma. — Other  peculiar  methods  of  extension  which 
occasionally  occur  must  be  attributed  to  the  implantation  or  accidental 
transplantation  of  carcinoma  cells.  This  so-called  implantation  carci- 
noma develops  upon  opposing  surfaces  of  the  lips,  of  the  tongue  and 
cheek,  and  of  the  labia,  upon  the  inner  surfaces  of  the  thigh  or  the 
vocal  cords.  One  surface  is  pi'imarily  involved,  the  opposing  surface 
secondarily. 

It  has  been  attempted  to  explain  the  development  of  multiple  carci- 
nomas in  the  gastrointestinal  tract,  in  the  respiratory  passages,  and 
urinary  tract  by  the  transplantation  of  carcinoma  cells  carried  from 
a  primary  tumor  situated  higher  (e.  g.,  carcinoma  of  the  tongue  and 
oesophagus,  carcinoma  of  the  oesophagus  and  stomach,  of  the  pharynx, 
tongue  and  larynx,  of  the  kidnej^  and  urinary  bladder).  It  is  exceed- 
ingly difficult  to  determine  whether  these  multiple  carcinomas  have 
developed  as  the  result  of  the  implantation  of  carcinoma  cells  from  a 
primary  tumor.  In  the  first  place  multiple  carcinomas  which  undoubt- 
edly have  developed  absolutely  independently  of  each  other  occur,  and 
in  the  second  place  it  is  possible  that  the  tumors  may  have  developed 
by  retrograde  lymphogenous  embolism.  The  latter  can  be  positively 
determined  only  when  a  l^nnphatic  vessel  filled  with  carcinoma  cells 
can  be  found  extending  between  the  primary  and  secondary  tumors. 

Macroscopic  Appearance  upon  Section. — ^lacroscopically  a  carcinoma- 
tous mass  is  grayish  red  in  color  and  somewhat  translucent  upon  section. 
Its  boundaries  are  rather  sharply  defined  against  the  surrounding  tissue, 
but  the  tumor  cannot  be  enucleated,  as  it  is  firmly  attached.  If  there 
are  no  areas  of  luvmorrhage,  necrosis,  or  softening,  the  cut  surface  of 
such  a  tumor  is  homogeneous. 

Upon  section  there  are  two  very  important  characteristics:  (1)  If  the 
stroma  is  well  developed,  yellowish  white  nests  of  epithelial  cells  may  be 
seen  with  the  naked  eye.  These  form  small,  round  foci  which  resemble 
when  expressed  by  digital  pressure  comedolike  masses  or  vermicelli;  (2) 
a  white,  milky  juice — the  so-called  cancer  milk — exudes  from  the  cut 
surface,  especially  of  soft  carcinomas,  and  may  be  easil}^  scraped  up  with 
a  knife. 

The  appearances  of  different  carcinomas  difl'er,  depending  upon  a 
number  of  different  factors.  If  the  tumor  contains  a  lai-ge  number  of 
blood  vessels  the  ti.ssues  will  have  a  dark  appearance.     Cai'cinomas  of 


936 


DIFFERENT   VARIETIES   OF   TUMORS 


the  mucous  membranes  and  viscera,  in  which  there  is  a  production  of 
large  amounts  of  mucus,  have  a  gelatinous,  glassy  appearance,  'i'he 
differences  in  macroscopic  appearance  also  depend  upon  the  character 
and  extent  of  the  regressive  changes.  Atrophy  and  necrosis  are  the 
most  important  regressive  changes  occurring  in  carcinomas.  These  are 
due  in  part  to  the  imperfect  nutrition  of  the  rapidly  growing,  decaying 
tissues;  in  part  to  the  obliteration  of  large  vessels  by  the  pressure  of 
the  tumor  masses  and  occlusion  of  the  vessels  by  carcinomatous  thrombi. 


Fig.  413. — Metastatic  Foci  in  the  Liver,  Secondary  to  a  Carcinoma  of  the  Rectum. 


Degeneration  of  the  cells  is  followed  by  softening.  After  the  ab- 
sorption of  the  liquefied  masses,  the  carcinomatous  area  in  a  viscus  be- 
comes depressed  and  contracted  forming  the  so-called  "  carcinoma 
navel."  Degeneration  occurring  in  the  skin  and  mucous  membranes, 
which  have  become  infiltrated,  leads  to  the  formation  of  carcinomatous 
ulcers.  Softening,  liquefaction,  and  ha'morrhage  lead  to  the  formation 
of  cysts,  which  should,  however,  be  difTerentiated  from  the  cavities 
occurring  in  cysts  which  have  become  carcinomatous.  The  tumor  masses 
also  may  become  calcified. 

Age,  Sex,  and  Frequency  with  which  Different  Tissues  are  Involved. 
— Carcinomas  develop  most  freciuently  in  middle  or  advanced  life,  the 
disease  being  most  common  in  the  fifth  and  sixth  decennia.  Not  infre- 
(|iiently  the  disease  occurs  at  an  earlier  age  during  the  second  and  third 
decennia.  The  disease  is  very  rare  in  children,  but  occasionally  con- 
genital carcinomas  are  observed,  developing  most  frequently  in  teratoid 
tumors. 


CARCINOMAS  937 

Carcinoma  is  more  frequent  in  the  female  than  male  sex,  the  relative 
proportion  being  six  to  fonr.  The  gieat  frequency  of  carcinoma  in  the 
female  is  due  to  the  frecpient  development  of  these  tumors  in  Die  female 
breast  and  in  the  organs  of  genei-ation  (Borst). 

The  statistics  of  different  authorities  concerning  the  frequency  with 
which  the  different  tissues  and  viscera  are  involved  differ.  According 
to  Borst  they  are  involved  in  the  following  order  of  frequency :  skin, 
stomach,  intestines  (rectum),  uterus,  mammary  gland,  oesophagus,  ovary, 
gall  bladder,  pancreas,  lung,  urinary  bladder,  larynx,  liver,  thyroid 
gland,  tongue,  kidney,  and  prostate.  As  a  rule,  but  a  single  primary 
carcinoma  develops. 

The  simultaneous  development  of  multiple  carcinomas,  which  are 
absolutely  independent  of  each  other,  is  the  exception.  Sometimes  mul- 
tiple independent  new  growths  develop  upon  the  skin  or  mucous  mem- 
brane which  is  already  involved  by  some  other  lesion — e.  g.,  upon  a 
leukoplakia,  a  senile  seborrhea,  an  X-ray  dermatitis,  a  xeroderma  pig- 
mentosum, a  tuberculosis  of  the  skin,  a  chronic  eczema  in  both  breasts 
following  a  chronic  mastitis,  in  the  intestinal  mucous  membrane,  the  seat 
of  multiple  polypi  (polyposis).  The  multiple  carcinomas  in  these  cases 
have  the  same  structural  relations  as  the  tissues  from  which  they  develop 
— for  example,  a  carcinoma  of  the  intestines  composed  of  cylindrical 
epithelium  may  develop  simultaneously  with  a  carcinoma  of  the  skin 
which  is  composed  of  squamous  epithelium. 

From  a  clinical  viewpoint  it  is  of  advantage  to  classify  carcinomas 
according  to  the  tissues  from  which  they  develop — for  example,  into  car- 
cinomas of  the  skin,  mucous  membranes,  and  glands. 

(a)  CARCINOMAS   OF   THE   SKIN 

The  majority  of  these  carcinomas  develop  from  the  surface  epi- 
thelium, and  are,  therefore,  composed  of  squamous  cells.  ]\Iore  rarely 
they  develop  from  the  glands  of  the  skin,  being  then  composed  of  cylin- 
drical cells. 

Origin  and  Histological  Characteristics. — As  a  squamous-cell  carci- 
noma grows,  solid  processes  composed  of  epithelial  cells  invade  the  sub- 
jacent tissues.  These  processes  are  composed  of  flat  epithelium  with 
oval  nuclei.  The  origin  of  these  cells  is  frequently  indicated  by  the 
formation  of  protoplasmic  bridges  and  cornification  which  give  to  these 
tumors  typical  histological  pictures.  In  many  carcinomas,  especially  in 
the  superficial  forms  developing  in  the  skin  of  the  face,  these  character- 
istics are  lacking  {vide  below).  The  young  cubical  or  cylindrical  cells 
corresponding  to  the  germinal  layers  of  the  epidermis  occupy  the  pe- 
riphery of  the  downgrowths,  while  the  older,  flat,  cornified  cells  are 
60 


938  DIFFERENT   VARIETIES   OF   TUMORS 

found  in  the  center.  The  colls  are  concentrically  arranged,  and  in  this 
WAX  the  epithelial  pearls,  so  characteristic  of  s(|uamons-cell  cai-ciiiouui, 
are  formed.  If  some  of  the  cytoplasm  of  the  cells  becomes  cornified 
while  the  remainder  undergoes  hyaline  or  fatty  changes,  peculiar  bodies 
are  formed  within  the  celLs  which  have  often  been  regarded  as  parasites 
(Borst).  Multinucleated  giant  cells  may  also  be  found  in  squamous- 
cell  carcinomas.  These  cells  which  develop  from  the  connective  tissue 
lie  between  the  stroma  and  the  epithelium  (vide  Petersen). 

Carcinomas  developing  from  sebaceous  glands  are  characterized  by 
broad,  clubbed  downgrowths  composed  of  flat  epithelium  which  often 
has  a  glandular  arrangement  and  is  undergoing  fatty  metamorphosis. 


/ 


1  i 


i 

i' 


\t 


*«^ 


,  i.ji«,  ■'I, 


vi 


•K^ 


J/' 


Fig.  414. — Six'tion  from  an  Epithelioma  of  the  Loweh  Lip,  Showing 
Epitiiki.ial  Pkaiu.s.      (From  Professor  Rcvaii's  Surgical  Clinic.) 

Carcinomas  also  occur  in  the  skin,  especially  upon  the  face,  which 
correspond  in  their  clinical  course  to  the  squamous-cell  carcinomas, 
occasionally  even  forming  nodular  tumors,  but  which  are  morpholog- 
ically different.  The  columns  of  cells  in  these  carcinomas  are  narrow 
and  pointed,  often  containing  a  luiiicii.  The  cells  are  elongated  and 
small. 

Carcinoma  Basocellulare. — The  delicate,  narrow  columns  of  cells,  cor- 
resjxjndiug  in  their  distribution  to  the  lymphatic  vessels,  give  to  these 
tumors  a  peculiar  histological  picture.    Usually  the  cells  do  not  become 


CARCINOMAS 


939 


cornified,  and  if  eornifieation  does  occur  it  is  limited  to  a  few  cells. 
The  glandlike  arrangement  of  the  epithelial  downgrowths  is  frequently 
so  striking  that  Krompecher  has  si)()ken  of  these  tumors  as  glandlike 

CARCINOMAS    ARISING    FROM    THE    SUPERFICIAL   EPITHELIUM.      Whether   his 

A-iew  that  these  carcinomas 
develop  from  the  basal 
cells,  while  the  squamous- 
cell  carcinomas  develop 
from  the  prickle  cells  is 
correct  or  not,  cannot  be 
answered  positively  at 
present.  There  are  a  num- 
ber of  authorities  who  do 
not  agree  with  him  in  this 
assertion.  According  to 
von  Ilansemann  and  Rib- 
bert  the  division  of  carci- 
nomas of  the  skin  int 
basal-  and  prickle-cell  car 
ciuomas  cannot  be  mad 
Ribbert  regards  the  tumor 
under  discussion  as  carci 
nomas  of  the  skin,  the 
cells  of  which  do  not  be- 
come cornified ;  Borst  re- 
gards them  as  endothelio- 
mas. Borrmann  groups  the  carcinomas  of  the  skin,  the  cells  of  which 
do  not  become  cornified,  as  CxVrcinomas  of  the  corium,  for  they  begin 
to  develop,  as  he  has  demonstrated,  in  the  corium.  He  believes  that 
they  develop  from  multiple,  misplaced  groups  of  epithelial  cells,  or  from 
displaced  anlage  of  hair  follicles,  sweat  and  sebaceous  glands. 

Most  Common  Sites  for  Development. — Carcinomas  of  the  skin  occur 
most  frequently  upon  the  face,  more  rarely  upon  other  parts  of  the 
body,  of  which  the  scalp,  the  skin  of  the  back  of  the  neck,  of  the  concha, 
the  external  auditory  meatus,  the  external  genitalia,  the  extremities,  and 
the  navel  should  be  mentioned. 

Predisposing  Factors. — These  tumors  develop  either  from  perfectly 
normal  skin  or  from  skin  which  has  previously  been  the  seat  of  some 
other  lesion.  Carcinomas  may  develop  from  benign  fibroepithelial 
growths,  such  as  warts,  papillomas,  cutiineous  horns,  hypertroiiliies  of 
hair  follicles,  from  adenomas  of  the  sebaceous  and  sweat  glands,  from 
atheromas  and  dermoid  cysts.  Irritation  associated  with  chronic  inflam- 
matory processes  favors  the  development  of  these  tumors.    The  following 


Fig.  415. — Superficial  Carcinoma  of  the  Skin  of 
THE  Nose,  the  Cells  of  which  do  not  Become 
Cornified.  (Basal  cell  carcinoma  of  Krompecher, 
corium  carcinoma  of  Borrmann.)  a,  Superficial 
ulcer;  b,  edge  of  the  ulcer;  c,  sebaceous  glands. 


940  DIFFERENT   VARIETIES  OF  TUMORS 

well-known  examples  may  be  cited :  Carcinomas  developing  after  re- 
peated attacks  of  erysipelas,  from  a  chronic  eczema  of  the  scrotum  or 
extremities  produced  by  soot  (chimney-sweep's  carcinoma),  from  irri- 
tation of  the  skin  of  the  hands  and  forearms  occurring  in  Avorkers  in 
paraffin  (paraffin  carcinoma)  and  tar,  and  from  syphilitic,  tuberculous, 
varicose,  and  trophoneurotic  ulcers.  A  carcinoma  of  the  skin  sometimes 
develops  early  in  life  upon  a  xeroderma  pigmentosum — a  congenital 
atrophy  of  the  skin  first  described  by  Kaposi,  which  is  associated  with 
a  peculiar  distribution  of  pigment.  Carcinomas  of  the  skin  develop  very 
frequently  in  advanced  life  from  a  senile  seborrhoea,  which  is  most  com- 
mon upon  the  temporal  and  frontal  regions,  the  cheeks,  and  the  dorsum 
of  the  nose.  The  relationship  between  senile  seborrhea  and  the  develop- 
ment of  carcinoma  has  been  noted  by  von  Volkmann,  Schuchardt,  and 
von  Bergmann  especially. 

Senile  Sehorrlioea. — Senile  seborrhtea,  which  is  usually  the  result  of 
uncleanliness,  is  characterized  by  a  proliferation  of  the  epidermis,  asso- 
ciated with  a  cornification  of  the  cells  and  an  accumulation  of  the  secre- 
tion of  the  sebaceous  glands  between  diiferent  layers  of  the  proliferating 
epidermis,  producing  an  occlusion  of  the  lumina  of  the  glands.  The 
lesions  appear  as  multiple,  dark-yellow  or  brown  scalelike  deposits,  which 
feel  oily  and  are  usually  well  circumscribed,  or  occasionally  as  wartlike 
growths.  The  scale  may  be  removed  if  the  surface  is  rubbed,  the  corium, 
which  bleeds  slightly,  then  being  exposed.  After  the  seborrhoeic  crusts 
have  been  removed  a  number  of  times,  a  superficial  ulcer  develops.  If 
kept  clean  and  treated  with  ointments,  such  an  ulcer  heals  rapidly,  if, 
however,  it  is  neglected  or  scratched,  it  remains  open.  The  ulcer  asso- 
ciated with  senile  seborrhoea  differs  from  that  of  a  carcinoma  in  that 
it  does  not  enlarge,  remains  superficial,  and  its  edges  do  not  become 
indurated. 

Scars  resulting  from  injuries  and  ulcers  of  the  skin  (syphilitic,  tu- 
berculous, varicose,  neuropathic,  burns),  and  chronic  fistuljE  may  also 
afford  the  conditions  which  favor  the  development  of  carcinoma.  Some- 
times a  carcinoma  follows  soon  after  an  injury,  developing  in  a  recent 
scar.  In  these  cases  a  single  trauma  must  be  regarded  as  the  essential, 
oi-  at  least  the  exciting  cause  of  tumor  formation.  A  carcinoma  may 
follow  repeated  injuries  of  the  lip  during  shaving,  developing  usually 
at  the  mucocutaneous  border  of  the  lower  lip.  Fistula*  from  which  car- 
cinomas occasionally  develop  usually  have  persisted  for  a  number  of 
years.  These  growths  may  develop  fi-oni  fistul;e  about  the  rectum,  from 
those  associated  with  sui)pui"itiiig  oj-  tuberculous  foci  in  bone,  or  remain- 
ing after  the  drainage  of  an  empyema. 

Carcinomas  of  the  skin  a])poar  in  three  forms:  the  superficial,  deep, 
and  papillary. 


CARCINOMAS  941 

(1)   SUPERFICIAL    CARCINOMAS   OF    THE    SKIN 

Appearance  and  Clinical  Course. — These  develop  as  small,  firm,  red 
nodules  which  are  usually  not  observed  at  first,  as  they  cause  no  pain. 
The  attention  of  the  patient  is  first  attracted  to  the  growth  after  it 
has  attained  considerable  size  or  when  the  epithelium  is  cast  off  and  the 
surface  becomes  covered  with  an  unsightly  crust.  When  the  latter  is 
removed  repeatedly  a  gradual  enlargement  of  the  underlying  ulcer  may 
be  noted.  A  benign,  superficial  defect  in  the  skin,  developing  after  an 
injury  or  the  removal  of  seborrhanc  crusts,  nia}^  impercei)tib]y  develop 
into  carcinoma. 

If  the  epithelium  is  retained  for  some  time  (this  occurs  especially  in 
basal-cell  or  corium  carcinomas),  a  superficial,  platelike  nodule  forms 
in  Avhich  frequently  small  cysts  with  clear  contents  maj'  be  recognized. 
The  cysts  are  produced  by  a  retention  of  secretion  in,  and  subsequent 
dilatation  of  the  glandlike  down-  ^^__^ 

growths  of  cells  found  in  basal-cell  ^-^        '   "  ~^-^  ^ 

carcinomas,  and  those  developing 
from  sweat  and  sebaceous  glands. 

The  form  and   clinical  course  it  \ 

of  superficial  carcinomas  are  char- 
acteristic  as   long    as    the   tumor 

remains    .superficial    and    extends  vj   if/^  j^ 

within  the  cutis.  ^     ';>  f. 

The  borders  of  the  ulcer  are 

but  little  indurated,  and  the  ulcer 

can   be  moved  with  the   skin   so  \^      ,  ' 

long  as  the  cells  do  not  invade  the  \  ^ 

deeper   tissues.      Invasion    of   the  \^  k  \ 

deeper  tissue,  w^hicli  is  usually  ac-  /    \  S  ^ 

companied   by  considerable   pain, 

occurs  only  after  the   lesion   has  ■      ^ 

persisted  a  number  of  years.  When      ^*-x. 

the  crust,  consisting  of  dried  seere-  "  _, ' 

tion    and   carcinoma   cells,    is    re-  y--     -    -^^ 

moved,  the  stroma,  which  carries 

.        .  Fig.  41G. — Sitpkrficial  C.\ncixoMA  of  the 

the  blood  vessels  and  is  easily  m-  Skix. 

jured,  bleeds.     The  floor   of  the 

ulcer  is  red  and  but  slightly  fissured,  as  it  does  not  extend  deeply  into 

the  subjacent  tissues. 

As  the  growth  invades  the  surrounding  tissues  a  firm,  wall-like,  but 
narrow,  border  is  formed  which  is  covered  by  the  raised,  undermined 
epithelium,  and  is  rather  sharply  delincd  against  the  floor  of  the  ulcer. 


942 


DIFFERENT  VARIETIES  OF  TUMORS 


As  ulceration  occurs  tlie  IxH'ders  of  the  ulcer  acquire  a  serpiginous 
or  jagged  outline  and  freciuently  appear  undermined,  as  the  careinonia 
cells  undergo  more  rapid  regressive  changes  than  the  epithelium  of  the 
border  of  the  ulcer. 

If  the  carcinoma  cells  in  the  center  of  the  ulcer  degenerate  com- 
pletely, the  proliferation  of  the  stroma,  followed  by  cicatricial  eon- 
traction,  becomes  marked 
and  radiating  folds  are 
formed  which  extend  into 
the  normal  skin  (Fig. 
416),  causing  distortion 
of  the  eyelids  and  lips. 
[' '  These  superficial  carci- 
nomas, frequently  called 
'  rodent  ulcers  '  by  Amer- 
ican and  English  sur- 
geons, may  heal  over  at 
certain  periods  of  the 
year.  An  old  man  pre- 
sents himself  in  a  clinic 
and  states  that  an  ulcer 
upon  the  face,  undoubt- 
edly of  carcinomatous  na- 
ture, becomes  raw  in  cold 
weather  and  heals  at  cer- 
tain periods  of  the  year, 
being  covered  by  a  deli- 
cate bluish  epithelium. 
The  raised  border  sur- 
rounding such  a  scar  still  indicates  the  nature  of  the  lesion.  These 
ulcers  may  heal  spontaneously,  but  the  temporary  healing  is  often 
attributed  to  some  ointment  which  may  have  been  applied  shortly  be- 
fore the  spontaneous  but  temporary  healing  occurred. 

"  The  spontaneous  healing  is  only  temporary.  Another  ulcer  soon 
forms  w'hich  extends  more  quickly,  and  then  it  may  be  seen  that  the 
carcinoma  cells  were  invading  deeper  tissues,  even  Avhen  the  ulcer  was 
apj)ai'ently  healing.  No  structures  seem  to  resist  the  ravages  of  the 
disease,  and  most  museums  contain  evidences  of  the  hideous  results  of 
rodent  ulcer  upon  the  face,  destroying  the  contents  of  the  orbit  and  the 
bones  of  the  nose,  and  laying  bare  the  nasopharynx.  Bands  of  fibrous 
tissue  long  resist  the  ulceration,  niid,  nllliough  the  vessels  may  be  dis- 
sected out  they  are  seldom  if  ever  laid  open.  AlF  this  time  the  general 
health  is  not  affected,  there  is  little  or  no  pain,  unless  the  eyeball  or 


Fig.  417. — Sui'iiUFiciAL    Carcinoma   of   the   Nose   of 
Ten  Years'  Standing. 


CARCINOMAS 


948 


nerve  trunks  are  involved,  and  the  lymphatic  nodes  remain  quite  un- 
complicated."—Allbutt's  "  System  of  Medicine,"  Vol.  IX,  p.  843.] 

Lupuslike  Carcinoma. — Von  Bergmann  has  described  a  peculiar  form 
of  superficial  carcinoma  occurring  in  the  skin  of  the  tcmi)oral  regions 
which  he  has  described  as  lupuslikc  carcinoma.  It  begins  with  the  for- 
mation of  small  nodules  in  the  skin.  These  disappear  without  ulcer- 
ating, leaving  a  scar  uncovered  by  hair.  New  nodules  later  develop 
about  the  scar,  finally  encircling  the  latter.  After  the  disappearance 
of  these  nodules  with  resulting  scar  formation,  new  nodules  develop 
about  the  periphery,  so  that  finally  a  large  area  of  skin  is  involved. 

These  superficial  carcinomas,  which  occur  most  frequently  upon  the 
face  and  scalp  (cheeks,  eyelids,  nose,  temporal  regions,  forehead,  or  exter- 
nal ear),  may  ])ersist  for  a  number  of  years  before  they  extend  deeper. 
Eventually  such  a  growth  may  transform  the  deeper  tissues  into  a  fri- 
able, ulcerating  mass,  and  rup- 
ture into  the  cavities  of  the  face 
or  destroy  the  bones  of  the  skull 
and  expose  the  dura  mater. 

Konig  describes  a  superficial 
carcinoma  occurring  in  a  woman 
ninety  years  of  age,  which  in- 
volved only  one  half  of  the  face 
after  persisting  for  twenty-five 
years,  and  another  case  (repre- 
sented in  Fig.  417)  occurring  in 
a  man  which  pursued  a  clinical 
course  of  ten  years'  duration  be- 
fore it  produced  a  complete  de- 
struction of  the  nose. 

A  superficial  carcinoma  of  the 
skin  grows  very  slowly,  usually 
in  the  form  of  a  superficial  ulcer 
with  slightly  elevated,  serpigi- 
nous, or  undermined  borders, 
with  a  slightly  fissured,  uneven 
base  which  bleeds  easily  when 
the  crust  covering  it  is  removed. 
Such  a   carcinoma   has   a   great 

tendency  to  cicatricial  contraction,  scar  formation,  and  apparent  healing. 
If  neglected  a  superficial  carcinoma  finally  involves  the  deeper  tissues. 

Metastases. — The  adjacent  lymph  nodes  are  involved  late,  usually 
not  before  the  lesion  has  involved  the  deeper  tissues.  When  the  lymph 
nodes  are  involved  they  become  enlarged  and  indurated. 


Fig.  418. — Si  I'l.ain  i.\i.    Ua^ai.  ( 'ki,l  ('-VKti- 

NOMA  OF  THE  SkIN  (COMPANION  TO  FiG. 

415).     Regarded  for  sonic  time  as  a  syphi- 
litic, later  as  a  tuberculous,  lesion. 


944  DIFFERENT   VARIETIES   OF   TUMORS 

Hasmatogenous  metastases  occur  in  neglected  cases  only. 

Diagnosis. — The  diagnosis  of  superficial  carcinomas  of  the  skin  is 
usually  easily  made  when  the  cliaracteristics  above  mentioned  are  kept 
in  mind.  The  chronicity  of  the  ulcer,  the  absence  of  a  dusky  margin, 
and  a  serpiginous  outline  at  once  distinguish  a  rodent  ulcer  from  the 
ulcer  of  tertiary  syphilis.  The  resemblance  between  an  ulcerated  gumma 
and  a  superficial  carcinoma  may  be  very  close,  and  it  is  often  difficult 
to  distinguish  between  the  two  without  a  microscopic  examination.  A 
rodent  ulcer  in  a  syphilitic  subject  may  be  curiously  modified. 

A  tuberculous  ulcer  has  flat,  irregular  borders  which  are  often  un- 
dermined for  some  distance,  and  a  distinctly  reddish  or  yellowish  floor 
containing  caseated  masses  and  tubercles.  Single,  isolated  syphilitic  and 
tuberculous  ulcers  are  the  exception.  They  are  usually  associated  with 
other  lesions  closely  adjacent  or  upon  other  parts  of  the  body,  while 
single  lesions  are  the  rule  in  carcinomas.  Superficial  ulcers  developing 
from  adenomas  of  the  sweat  glands  and  following  seborrhea  never  have 
indurated,  thickened  borders. 

Treatment. — Thorough  excision,  carried  into  healthy  tissues,  is  the 
only  successful  treatment,  as  rapid,  safe,  and  permanent  healing  cannot 
be  secured  by  any  of  the  other  procedures  which  have  been  recom- 
mended, such  as  cauterization  with  the  hot  iron,  different  caustic 
solutions  and  pastes,  and  the  use  of  Rontgen  and  radium  rays.  If 
the  excision  is  properly  performed,  the  carcinoma  recurs  in  a  very 
few  cases  (in  4.5  per  cent,  according  to  Borrmann).  Extensive  and 
deep  recurrences  follow  so  frequently  the  apparent  healing,  which  may 
also  occur  after  the  use  of  the  dry  aseptic  dressing  (von  Bergmann), 
produced  by  the  agents  above  mentioned,  that  a  w^ord  of  warning  should 
be  spoken.  Lexer  has  seen  a  number  of  cases  in  which  the  carcinoma 
became  inoperable  after  having  been  treated  for  a  number  of  months 
with  Rontgen  and  radium  rays. 

The  defect  resulting  from  the  excision  of  the  ulcer,  which  should 
be  carried  well  into  the  healthy  tissues,  should  be  repaired  by  a  plastic 
operation.  Defects  upon  the  forehead  and  body  should  be  covered  with 
epidermal  strips.  The  surface  of  bone,  when  invaded,  should  be  chis- 
eled away.  The  eye  should  be  enucleated  as  soon  as  a  carcinoma  de- 
veloping upon  the  lid  invades  the  orbit  and  the  bulb. 

Diseased  or  suspicious  lymph  nodes,  together  with  the  connective 
tissue  and  fat  surrounding  them,  should  be  radically  removed.  Often 
the  enlargement  of  the  regional  lymi)h  node  is  of  an  inflammatory 
nature,  being  due  to  the  absorption  oi'  infectious  materials  from  the 
ulcer.     Sometimes  the  nodes  are  tuberculous. 

Carcinomas  of  the  face  may  finally  extend  deeply,  destroying  the 
bone  and  exposing  the  dura  mater  or  invading  the  ethmoid.    They  then 


CARCINOMAS  945 

become  iuoperable.  Caustic  ])a.stcs  (zinc  chloi'id),  the  use  of  the  actual 
cautery  and  of  compresses  of  hydrogen  peroxitl  solution  are  indicated 
to  retard  the  extension  of  the  disease  and  overcome  the  odor  associated 
with  putrefaction. 

(2)  DEEP    CARCINOMAS    OF    THE    SKIN 

Origin. — These  carcinomas  develop  from  small,  round  nodules  which, 
when  situated  in  the  deeper  tissues,  originate  in  the  glands  of  the  skin 
(sebaceous  glands,  hair  follicles,  perhaps  also  sweat  glands)  or  from 
superficial  carcinomas  which  have  existed  for  a  long  time.  They  have 
the  characteristics  of  new  growths,  which  are  often  almost  completely 
wanting  in  the  superficial  carcinomas  of  the  skin.  They  occur  most 
frequently  upon  the  face,  involving  the  nose,  the  eyelids,  and  the  muco- 
cutaneous border  of  the  lips.  When  the  lips  are  involved,  the  clinical 
picture  resembles  very  closely  that  of  carcinoma  of  the  mucous  mem- 
branes.    These  tumcu-s  are  I'arely  found  on  other  parts  of  the  body. 

Appearance  and  Clinical  Course. — They  rapidly  invade  the  surround- 
ing tissues  and  degenerate  to  form  ulcers,  the  bases  of  which  are  indu- 
rated and  fused  with  the  underlying  tissues  (fascia,  bone,  etc.).  Fissures, 
spaces,  and  craterlike  depressions,  covered  by  crusts  and  degenerated 
epithelium,  and  in  which  easily  bleeding  carcinoma  tissue  may  be  found, 
are  present  in  the  floor  of  these  ulcers.  Plugs  of  carcinoma  tissue  may  be 
expressed  from  the  ulcer  if  lateral  digital  pressure  is  made.  The  edges  of 
the  ulcer  are  raised  and  definitely  infiltrated.  They  are  hard  to  the  touch, 
and  the  induration  may  extend  to  the  tissues  beneath.  The  edges  of  the 
ulcer  are  pinkish  in  color  and  often  marked  by  dilated  capillaries.  The 
discharge  is  seroha^morrhagic  in  character  and  filled  with  the  decompos- 
ing products  of  cellular  debris.  If  the  ulcer  is  large,  the  secretion  has 
a  peculiar  and  offensive  odor.  Severe  hamiorrhages  may  follow  the 
ulceration  of  large  arteries  in  the  deeper  parts  of  the  new  growth. 

Nodular  or  wartlike  projections  may  develop  in  the  floor  of  such 
an  ulcer  later  in  the  clinical  course,  and  project  above  the  level  of  the 
surrounding  skin,  forming  a  transitional  stage  to  the  papillary  form  of 
carcinoma  of  the  skin. 

Metastases. — The  regional  lymphatic  nodes  become  extensively  in- 
volved and  transformed  into  large  nodular  tumors  early  in  the  course 
of  the  disease. 

Hfematogenous  metastases  are  not  rare. 

Treatment. — The  course  of  this  form  of  carcinoma  is  so  rapid  that 
the  diagnosis  mast  be  made  early  if  the  treatment  is  to  be  effectual. 
Any  wart  or  sear  occurring  in  old  people,  which  begins  to  enlarge  rap- 
idly and  ulcerate,  or  rapidly  developing  and  ulcerating  warts  or  papil- 
lomas, which  form  upon  an  iiiflanunatory  base  (for  example,  the  warts 


946 


DIFFERENT   VARIETIES  OF   TUMORS 


developing  upon  the  chronic  eez.ema  occurring  in  chimney  sweeps), 
should  arouse  suspicion  of  malignancy,  even  when  the  definite  character- 
istics of  carcinoma  are  wanting. 

Removal  of  the  growth  by  excision  is  the  only  treatment  that  should 
be  considered.  The  excision  should  be  carried  well  into  healthy  tissue, 
and  the  regional  lymph  nodes  should  be  removed.  It  is  frequently  neces- 
sary to  resect  the  bone  adjacent  to  the  growth. 

The  same  methods  should  be  employed  in  the  treatment  of  inoper- 
able cases  as  have  already  been  described  in  discussing  superficial  car- 
cinomas of  the  skin. 


(3)   PAPILLARY    CARCINOMAS    OF   THE    SKIN 

,  Appearance  and  Clinical  Course. — These  carcinomas  are  characterized 
by  the  early  growth  of  the  tumor  tissue  above  the  level  of  the  skin. 
They  usually  develop  from  small  iiodnles,  wartlike  growths,  or  from 
carcinomatous  ulcers,  and 
usually  appear  as  firm 
pedunculated  or  sessile 
tumors  with  hard  infil- 
trated bases,  overhang- 
ing borders,  and  nodular, 
fungoid,  cauliflowerl ike 
or  papillomatous  surfaces 
in  which  deep  depressions 
may  be  seen  and  which 
are  frequently  covered 
by  horny  masses  or  crusts 
composed  of  dried  secre- 
tion. The  skin  usually 
stops  abruptly  at  the 
margin  of  such  a  growth. 


l''iu.  419. — NoDui-Aii  Cakcindma  which  L)i:vKLOiM;n  ui'on  a  Vauicose  Ulceu  of  thk  Leg 
Tlie  fibula  has  been  partially  destroyed  by  the  growth. 


CARCINOMAS  947 

Upon  section,  loii^-  bi'Jiiiclicd  |)apill;ii-y  urowths  arc  seen  (l«>velopiim-  from 
the  cnrt'inoiiiatous  masses,  which  in  the  he^iniiin^',  at  h'ast,  do  not  extend 
far  into  the  subjacent  tissues. 

Carcinomas  of  the  skin  of  the  extremities  (Fij^'.  420)  and  of 
the  penis,  and  carcinomas  deve]opin>i-  in  the  mucous  memhi-ane  of 
the   tjlans  and  inner  layer  of  tlie   pi-epuce   produce   the  same   clinical 


Fig.  420. — C.\uliflowerlike  Carcinoma  of  the  Back  of  the  Hand  which  Developed 
IN  A  Scar  One  and  a  Half  Years  After  an  Injury.  (Male  patient  sixty  years  of 
age.) 

picture.  Carcinomas  of  the  skin  of  the  face  assume  this  picture  more 
rarely. 

This  form  of  carcinoma  develops  most  freqnentl^y  from  libroepithelial 
growths  and  in  scars  and  ulcers ;  occasionally  from  atlieromas  and  der- 
moid cysts. 

Rapid  enlargement  of  a  wartlike  growth  should  arouse  suspicion  of 
malignancy.  When  a  papillary  earcinonui  develops  upon  an  old  nicer, 
small,  hard  nodnles  first  appear  within  the  flabby  granulations,  and  then 
infiltration  and  induration  of  its  edges  quickly  follow. 

Metastases. — The  adjacent  lymph  nodes  rapidly  become  involved. 
General  metastases  may  occur. 

Treatment. — If  early  and  extensive  excision  is  performed,  recovery 
without  metastases  may  occur.  In  papillary  carcinomas  of  the  extrem- 
ity which  have  invaded  and  passed  through  the  fascia,  amputation  may 
afford  the  only  hope  of  permanent  cure.  Excision  carried  well  into 
healthy  tissues  should  be  attempted  only  when  the  growth  is  still  lim- 
ited and  is  not  adherent  to  the  underlying  tissues  (tendons,  ])one).  The 
penis  should  always  be  amputated  Avhen  a  careinonui  involves  this 
organ. 

The  other  rules  for  the  treatment  are  the  same  as  described  in  dis- 
cussing other  forms  of  carcinoma  of  the  skin. 


948 


DlFFERExVT  VARIETIES  OF  TUMORS 


(b)  CARCINOMAS   OF   THE   MUCOUS   MEMBRANES 

Clinical  Forms. — Carcinomas  of  the  luiioous  membranes  appear  in  a 
number  of  different  forms;  sometimes  developing  as  pedunculated  or 
sessile,  nodular  tumors,  sometimes  as  fungous,  cauliflowerlike,  papillom- 
atous, or  villous  growths,  sometimes  as  superficial  or  deep  ulcers,  and 
finally  as  dift'use  infiltrations. 

They  are  very  different  morphologically.  The  difference  depending 
mostly  upon  whether  the  tumor  develops  from  mucous  membranes  cov- 
ered with  squamous  or  cylindrical  epithelium,  or  whether  it  develops 
from  glands  within  the  nuieous  membranes. 

Squamo}(S-cell  Carcinomas. — Squamous-cell  carcinomas  with  cornifi- 
cation,  similar  to  those  of  the  skin,  occur  most  frequently  upon  the 
tongue  and  lips.  The  lower  lip  is  more  frequently  involved  than  the 
upper  lip.  They  also  occur  in  all  parts  of  the  mouth  cavity  (cheeks, 
floor  of  the  mouth,  soft  palate,  tonsils),  in  the  larynx,  the  oesophagus, 
the  cardiac  end  of  the  stomach,  in  the  vagina,  the  cervix  of  the  uterus, 
upon  the  mucous  portions  of  the  labia,  the  prepuce,  and  the  glans  penis. 


.J 


Fig.  421. — Carcinoma  of  the  Nkck,  Second.^ry  to  a  Carcinoma  of  the  Lip.  Involve- 
rnciit  of  the  skin  following  extension  from  lymph  nodes.  (From  Professor  Bevan's 
Surgical  Clinic.) 

Carcinomas,  the  cells  of  which  become  cornified,  may  also  develop  from 
the  ti-ansitional  epithelium  of  the  lu'lnaiy  jiassages. 

Tn  the  fare  cases  in  which  the  S(|uniiious-cell  carcinomas  develop  in 
nnu'oiis  m('m])rane  covered  with  cylindi-ical  epithelium  (gall  bladder, 
stomach,   trachea),   it  must  be  supposed   that  they   develop   from   dis- 


CARCINOMAS  949 

placed  embryonal  tissue  consist  in**-  of  squamous  cells  or  from  epithelium 
which  has  undergone  metaplasia  as  the  result  of  chronic  inflammation 
or  long-continued  pressure. 

Predisposing  Factors. — Often  some  other  lesion  of  the  mucous  mem- 
brane prepares  the  way  for  the  development  of  a  carcinoma.  Carci- 
nomas of  the  mucous  mem- 
branes, like  carcinomas  of  the 
skin,  may  develop  from  fibro- 
epithelial  growtlis,  from  ulcers 
of  all  kinds  (especially  the  tu- 
berculous and  syphilitic),  from 
sears  and  wounds.  Injuries 
produced   by  the   sharp    points  fj^.  422.— Car^^^'5^  of  the  Tongue. 

of  carious  teeth  and  the  disease 

known  as  leucoplakia  or  psoriasis  liiigme  are  of  about  equal  importance 
as  etiological  factors  in  the  development  of  carcinoma  of  the  tongue 
and  cheek. 

Leucoplakia. — Leucoplakia  is  characterized  by  the  gradual,  painless 
formation  of  white,  light  gray,  or  opal,  slightly  elevated  plaques,  which 
are  observed  most  frequently  upon  the  dorsum  of  the  tongue,  and  then, 
in  order  of  frequency,  upon  the  margins  and  lower  surface  of  the 
tongue,  upon  the  mucous  membrane  of  the  cheek,  especially  near  the 
angle  of  the  mouth,  upon  the  lips,  and  more  rarely  upon  the  soft  palate. 
The  plaques,  which  usually  are  sharply  defined,  are  irregular  in  shape 
and  vary  in  size.  These  epithelial  plaques,  which  are,  as  a  rule,  firmly 
attached,  are  formed  by  the  excessive  proliferation  and  cornification 
of  the  epithelium.  Not  infrequently  epithelial  processes  are  found 
within  them  which  extend  through  the  basement  membrane  to  penetrate 
the  submucous  tissue,  indicating  that  a  carcinoma  has  already  com- 
menced to  develop. 

Leucoplakia  may  develop  in  middle  life  and  remain  entirely  harm- 
less as  long  as  thirty  years,  or  longer.  At  any  time,  however,  a  nodular 
induration  associated  with  pain  may  develop  in  the  mucous  membrane 
beneath  the  white  plaque.  The  induration  may  be  due  to  different 
causes.  In  the  majority  of  cases  the  painful  induration  is  due  to  a 
transitory  inflammation  of  the  mucous  membrane  beneath  the  white 
patch,  which  has  become  rough  and  fissured.  Sometimes  the  nodule 
enlarges  and  becomes  more  indurated,  instead  of  subsiding,  indicating 
the  beginning  of  carcinoma  formation.  In  many  cases  the  development 
of  multiple  carcinomas  at  dift'erent  points  in  the  tongue,  cheeks,  and 
lips  may  be  observed  after  long  intervals.  Benign  papillomas  may  de- 
velop upon  a  leucoplakia  as  well  as  carcinomas  (von  Bergnumn)  (Fig. 
423).     The  development  of  nodules  upon  a  leucoplakia  should  always 


950 


DIFFERENT   VARIETIES  OF   TUMORS 


arouse  suspicion.     When  a  nodule  develops  it  should  be  removed  and 
examined  microscopically  in  order  to  make  a  positive  diagnosis,  and  the 

proper  treatment  should  then  be  instituted. 
Benign  growths  should  be  removed,  as  they 
may  become  malignant  at  any  time. 

Leucoplakia  occurs  almost  exclusively  in 
men,  most  frequently  in  those  who  smoke  to 
excess.  It  is  rare  in  women,  even  in  those 
addicted  to  smoking.  Tobacco  must  there- 
fore have  the  same  relation  to  carcinoma  of 
the  mucous  membranes  that  tar  and  paraffin 
have  to  carcinoma  of  the  skin  (von  Berg- 
mann). 

The  treatment  of  leucoplakia  is  successful 
only  when  smoking  is  stopped.  It  consists 
usually  of  the  use  of  non-irritating  mouth 
washes.  When  the  plaque  becomes  fissured 
and  an  inflammatory  zone  develops  about 
the  lesion,  the  actual  cautery  is  to  be  recom- 
mended. Hard  nodules  w^hich  continue  to 
enlarge  indicate  the  beginning  of  carcinoma 
formation.  These  should  be  excised,  and  the  spindle-shaped  or  cunei- 
form incision  (depending  upon  whether  the  lesion  is  situated  in  the 
middle  or  uixni  th*'  margin  of  the  tongue,  upon  the  inner  surface  of 

the  lip  or  upon  the  red  margin) 
should  be  carried  well  into  the 
deeper  tissues. 


FiG.,423. — a,  Papilloma,  Cor- 

NIFICATION    OF    THE     CeLLS 

Covering  the  Growth  is 
Marked,  b,  Carcinoma- 
tous Ulcer  with  Indura- 
ted, Craterlike  Edges. 
The  papilloma  and  carci- 
noma are  separated  by  an 
area  of  leucoplakia.  (Von 
Bergmann's  Handbook  of 
Practical  Surgery.) 


Fia.  424. — Papillary  Carcinoma  of  the  Corona  Glandis  and  Prepuce 


CARCINOMAS 


951 


[We  have  no  method  of  eiifin.o-  h'ueoplakia  at  the  pi-esent  time.  If 
the  epithelium  affected  is  removed  a  leueoplakia  j-cfoi-ins  when  the  epi- 
thelium regenerates.] 

Squamous-cel]  carcinomas  of  the  mucous  mem})ranes  appear  in  forms 
very  similar  to  those  of  their  companions  in  the  skin.  The  deep  car- 
cinomas with  craterlike,  deeply  fissured  ulcers  which  have  raised,  often 
nodular,  edges  and  an  extensively  infiltrated  base  occur  most  frettumtly 
upon  the  tongue  and  the  lower  lip. 

The  papillary  forms,  associated  Avith  superficial  and  deep  ulcers, 
occur  in  the  intestinal  mucous  membranes,  in  the  mucous  membranes 
of  the  cheek,  jaws,  pharynx  and 
larynx,  the  urinary  bladder,  the 
pelvis  of  the  kidney,  and  espe- 
cially upon  the  prepuce  and 
glans  penis.  The  cells  composing 
the  carcinomas  of  the  prepuce 
and  glans  have  a  marked  tend- 
ency to  undergo  cornification. 

The  nodular  infiltration,  the 
boundaries  of  which  are  indis- 
tinct, is  covered  by  normal  nui- 
cous  membrane  in  the  beginning. 
Later  ulceration  occurs,  nodular 
growths  project  above  the  sur- 
face of  the  ulcer,  and  the  new 
growth  rapidly  invades  sur- 
rounding structures.  A  papil- 
lary carcinoma  involving  secondarily  the  branches  of  the  trigeminal  nerve 
may  caiLse  excruciating  pain  which  can  scarcely  be  controlled  by  morphin. 

Carcinomas  of  the  mucous  membranes  bleed  oftener  and  undergo 
putrefactive  changes  much  earlier  than  those  of  the  skin.  Haemorrhage 
may  be  the  first  symptom  of  a  carcinoma  of  the  bladder  or  of  the  pelvis 
of  the  kidney.  The  discharge  of  a  foul-smelling  secretion,  whrieh  occurs 
especially  with  carcinomas  of  the  mouth,  may  render  it  almost  impos- 
sible for  one  to  remain  near  the  patient.  The  swallowing  of  this  secre- 
tion may  cause  severe  digestive  disturbances  and  diarrhea;  aspiration 
n\ay  cause  bronchopneumonia. 

Stenosis  of  the  larynx  and  (esophagus  follows  the  contraction  or  pro- 
liferation associated  with  these  new  growths  occurring  in  these  organs. 
Sudden  dyspnoea  may  follow  inflammation  of  the  nnicous  membrane 
surrounding  an  ulcer  of  the  larynx.  The  swelling  of  the  mucous  mem- 
brane surrounding  a  carcinoma  of  the  oesophagus  may  be  great  enough 
to  prevent  even  the  swallowing  of  liquids. 


Fig.  425. — Xodulah  Carcixo.ma  of  the  Maxil- 
la (woman  forty-two  years  of  age).  Healed 
by  total  resection. 


952 


DIFFERENT   VARIETIES  OF   TUMORS 


Carcinomas    Developing    in    Mucous    Membranes    ivith    Cylindrical 
Epithelium. — The  epithelial  down- 
growths   developine;  in   carcinomas 


Fig.  426. — Deep  Carcinoma  of  the  Penis  with  Destruction  of  the  Glans. 

arising   from   mucous  membranes   covered   with   cylindrical   epithelium 
have  a  glandlike  or  tubular  form,  and  are  lined  with  stratified,  more 

rarely  with  simple  cylindri- 

^mt'^iWm'^^  \  \  ^'^^  epithelium. 

The  processes  in  such  a 
tumor  branch  frequently, 
connnunicating  with  each 
other,  and  the  histological 
picture  varies,  as  the  proc- 
esses may  be  cut  trans- 
versely, obliquely,  or  longi- 
tudinally. 

Goblet  cells  may  be  found 
in  large  numbers.  Thej^  are 
rarely  evenly  distributed  as 
they  are  in  glands.  Groups 
of  these  cells  may  be  irregu- 
larly distributed  throughout 
the  section. 

Some  of  the  carcinomas 
developing  from  glandular 
epitlieliiuii  have  a  similar 
tubular  sti'ucture,   while   in 


<- 


Fif!.  427. — Carcinoma  of  the  Lower  Lip  which 
HAS  Become  Nouular  Following  Ulceration. 
Tlio  tumor  is  adherent  to  tlie  mandible  and  is 
fused  with  tlie  submaxillary  lymph  nodes. 


CARCINOMAS 


953 


others  the  processes  whieh  invade  the  siirronndintj:  tissues  are  solid.  The 
division  of  glandular  eareinomas  into  the  adenomatous  and  solid  varie- 
ties is  therefore  jusliliahlc. 

Colloid  CarcinutHCis.  —  The  colloid  carcinomas  (nnicoid)  in  which 
there  is  the  formation  of  considerable  mucus  is  another  variety  of  this 
form  of  carcinoma. 

The  cells  composing  a  colloid  carcinoma,  are  filled  with  mucus,  and 
appear  as  large,  round,  swollen  structures,  which,  because  of  the  lat- 
eral position   of  their  nuclei,  have  been   called  the  "seal-ring   cells" 
(Ribbert).     The  mucous 
masses  which  are  secreted 
either  fill  the  alveoli  or 
separate    the    cells    from 
the  thin  connective-tissue 
bands  of  the  stroma. 

A  colloid  carcinoma 
is  composed  of  a  soft, 
glassy,  translucent  tissue 
from  which  a  viscous  sub- 
stance is  discharged  when 
the  tumor  is  sectioned  or 
scraped  with  a  knife. 

Most  Common  Sites  for 
Development. — The  cylin- 
drical and  glandular  car- 
cinomas of  the  mucous 
membranes  occur  most 
frequently  in  the  gastro- 
intestinal tract,  most  commonly  at  the  pylorus  and  on  the  lesser  curva- 
ture of  the  stomach,  in  the  c»cum,  at  the  hepatic  and  splenic  flexures 
of  the  colon,  and  in  the  rectum. 

These  tumors  may  also  develop  in  the  nasal  nnicous  membrane,  re- 
spiratory passages,  the  gall  bladder,  the  cervix  and  the  body  of  the 
uterus;  also  from  the  epithelial  remains  of  the  branchial  clefts  (branchi- 
ogenic  carcinoma)  and  from  mixed  tumors.  Ulcers  of  the  mucous  mem- 
brane (ulcer  of  the  stomach)  and  fibroepithelial  tumors  (nniltiple  in- 
testinal polypi)  form  with  about  equal  frequency  the  base  fi-om  which 
these  carcinomas  develop. 

Clinical  Course. — These  carcinomas  begin  as  hard,  nodular,  infiltrated 
areas  beneath  the  mucous  membrane,  apparently  at  first  well  delimited. 
Regressive  changes  soon  occur,  resulting  in  the  formation  of  superficial 
and  deep  ulcers  which  in  the  intestine  and  at  the  pylorus  are  sur- 
rounded by  hard  raised  borders,  and  usually  tend  to  surround  the  lumen 
61 


III 


•I    VI.INDKK'AI.     I    1.1,1,    i;.\KL'l.\l.)M.V 

Rectum. 


954 


DIFFERENT    VARIETIES   OF   TUMORS 


of  the  bowel  or  pylorus  re- 
spectively. If  the  nodular, 
cauliliowerlike,  or  papillary 
growths  predominate,  the 
lumen  may  be  completely 
occluded.  The  cicatrizing 
form  of  carcinomatous  ul- 
cer encircling  the  bowel 
may  also  produce  a  stenosis 
of  the  bowel,  sometimes  so 
reducing  the  lumen  that 
it  is  impossible  to  pass  a 
probe  or  a  grooved  direc- 
tor through  it.  Ulceration, 
haemorrhage,  and  putrefac- 
tive changes  develop  espe- 
cially rapidly  in  carcino- 
mas of  the  gastrointestinal 
tract,  as  they  are  exposed 
to  the  continual  irritation  of  the  intestinal  contents.  They  are  asso- 
ciated, depending  upon  the  position  of  the  tumor,  with  the  vomiting  of 
blood,  the  discharge  of  blood-stained  mucus,  and  the  usual  symptoms 

b       ^  b 


Fig.  429. — Colloid  Carcinoma  of  the  Rectum. 
Section  of  specimen  represented  in  Fig.  431. 


Fig.  430. — Noijulak  and  Papillomatous  Carcinoma  of  the  Rectum  {b).     a,  Multiple 
Papillomas.    Resection  Pueparation. 


CARCINOMAS 


955 


of  intestinal  catarrh  caused  by  the  passaije  of  putrefyiii<;  masses  over 
the  mucous  memljrane. 

Many  of  these  tumors  infiltrate  rapidly  and  extensively  the  walls  of 
the  stomach  and  intestines  without  ulcerating.  The  part  involved  then  be- 
comes transformed  for  a  considerable  extent  into  a  rigid,  tubelike  struc- 
ture, the  walls  of  which  are  thickened  and  lined  by  a  nodular  mucous 
membrane  which  cannot  be  displaced  upon  the  subjacent  tissue.  The  de- 
velopment of  small  nodules  and 
fine  strands  in  the  serosa  indi- 
cate lymphatic  involvement. 

If  a  carcinoma  involving  the 
stomach  or  intestine  extends 
through  their  walls  and  rup- 
tures into  the  peritoneal  cavity, 
a  general  or  local  putrefactive 
peritonitis  follows,  depending 
upon  whether  or  not  adhesions 
have  formed.  An  intestinal  loop 
or  a  part  of  the  stomach  in- 
volved by  a  carcinoma  may  con- 
tract adhesions  with  a  neighbor- 
ing viscus,  and  then  the  latter 
becomes  involved.  Adhesions 
may  be  contracted  with  an  in- 
testinal loop  or  some  hollow 
viscus,  such  as  the  bladder,  and 
when  ulceration  and  perforation 
occur  a  communication  is  estab- 
lished between  the  two. 

Colloid  carcinomas  are  found 
most  frequently  in  the  rectum, 
but  they  also  occur  in  the  stom- 
ach and  cceeum  (Fig.  431).  They 

form  large  growths,  invade  wide  areas,  and  have  a  tendency  to  progress- 
ive infiltration  of  the  intestinal  wall,  the  mesentery,  omentum,  the 
appendices  epiploicfe,  and  the  entire  peritoneum. 

Importance  of  Early  Diagnosis. — It  is  essential  that  an  early  diag- 
nosis be  made  in  these  cases,  in  order  that  efficient  treatment  may  be 
instituted.  This  is  often  difficult,  as  the  physical  signs  and  symptoms 
are  not  pronounced,  and  the  latter,  even  when  marked,  frequently  re- 
semble closely  those  occurring  in  other  diseases.  Therefore  it  is  fre- 
quently the  ease  that  a  positive  diagnosis  is  made  when  the  carcinoma 
is  too  far  advanced  for  radical  removal. 


Fig.  431. — Colh->id  Carcinoma  of  the  Rectum 
Removed  from  a  Young  Woman  Twenty- 
three  Years  of  Age. 


956 


DIFFERENT   VARIETIES  OF   TUMORS 


Carcinomas  developing  in  the  mouth  are  naturally  noted  early.    They 
are,  however,  often  mistaken  for  syphilitic  lesions,  as  they  are  frequently 


Fig.  432.  —  Nodular,  Circular  Carcinoma  of  the  C^cum,  the  Center  of  which  is 
Ulcerated.  The  carcinoma  was  situated  close  to  the  ileocsecal  valve.  Removed 
from  a  man  thirty-five  years  of  age.  Three  years  have  elapsed  since  operation  with  no 
recurrence. 


surrounded  by  or  associated  with  leucoplakia.  If  a  piece  of  tissue  is 
excised  for  microscopic  examination,  it  should  be  large  enough  to  per- 
mit of  a  positive  di- 
agnosis and  should  be 
taken  from  the  proper 
part  of  the  lesion. 

Symptoms.  —  The 
symptoms  depend  up- 
on the  position  of  the 
tumor  and  upon  inter- 
ference with  the  func- 
tion of  the  organ  in- 
volved. A  carcinoma 
of  the  larynx  causes 
hoarseness ;  of  the 
stomach,  vomiting  and 
chronic  gastritis ;  of 
the  intestines,  symp- 
toms of  stenosis  and 
chronic  ileus;  of  the 
r  e  c  t  u  m ,  hn?morrhage 
and  the  discharge  of 
l)l()()(l-st;uned  nuicus.  A 

I'lo.  4:3:J.— Ulcerated  Sui-euficial  Carcinoma  of  the  luilior  of  the  bladder  is 

Rectum,     a,  Cratcrlikc  margin;  h,  ulcer.  aSSOciatcd   with  hsemOr- 


CARCINOMAS 


957 


rhage  and  the  retention  of  urine ;  while  a  tumor  of  the  antrum  of 
Ili^hmore  may  be  a.ssoeiatcd  witli  tlie  symptoms  of  an  empyema  of  the 
antrum,  following'  the  aecunnilalion  and  sul)S('(|ueiit  ini't-ction  of  the 
seeretion  of  the  mucous  meiiibi-aue.  The  symptoms  pi-odueed  by  a  car- 
cinoma developing'  in  any  of  the  organs  or  parts  above  mentioned  may 
be  confused  with  those  associated  with  relatively  hanidess  lesions. 

If  the  tumor  is  visible  and  palpable,  the  diagnosis  can  usually  be 
easily  made,  as  the  form  of  the  ulcer,  the  induration  of  its  edges,  the 
appearance  of  its  floor,  the  character  of  the  secretion,  and,  when  far 
advanced,  the  infiltration  of  adjacent  tissues  and  the  involvement  of 
regional  lymph  nodes  are  quite  characteristic.     In  carcinomas  involving 


-a 


Fig.  434. — Section  through  Carcinoma  Represented  in  Fig.  433.     a,  Mucous  membrane 
at  margin  of  the  ulcer;  6,  tumor  tissue. 

the  gastrointestinal  tract  it  is  often  necessary  to  perform  an  exploratory 
laparotomy  before  a  positive  diagnosis  can  be  made.  If  a  tumor  can 
be  palpated  through  the  abdominal  wall,  the  diagnosis  may  be  made,  but 
in  the  majority  of  these  cases  the  tumor  has  then  extended  so  far  that 
radical  removal  is  impossible.  It  is  advisable,  when  the  symptoms  indi- 
cate a  carcinoma  of  the  gastrointestinal  tract,  to  perform  an  exploratory 
laparotomy,  in  order  that  an  early  and  positive  diagnosis  may  be  made. 
Treatment. — If  the  diagnosis  is  made  early  enough  to  permit  of 
operative  procedures,  the  tumor  and  the  lymph  nodes  which  drain  it 
should  be  removed. 


(c)  CARCINOMAS   OF   GLANDULAR   ORGANS 

Histology. — Carcinomas  developing  in  the  various  glands  correspond 
more  or  less  closely,  histologically,  to  the  glands  in  whicli  they  occur, 
and  therefore  differ  Mudely  in  their  structure.  Usually  an  adenomatous 
can  be  dififerentiated  from  a  solid  type,  depending  upon  whether  the 
cells  are  arranged  in  the  form  of  gland  tubules  or  solid  processes.  The 
epithelial  cells  may  be  cylindrical,  cubical,  or  polymorphous,  and  ar- 
ranged in  a  single  layer  or  stratified.     The  secretion  of  the  cells  differ, 


958 


DIFFERENT   VARIETIES  OF   TUMORS 


depending  upon  th(>  origin  of  the  tninor.  The  cylindrical  cells  in  a 
carcinoma  of  the  thyroid  may  secrete  colloid,  while  those  foinid  in  a 
primary  carcinoma  of  the  liver  may  secrete  bile.  The  cylindrical  cells 
found  in  carcinoma  of  the  breast  may,  like  those  found  in  adenocarci- 
noma of  the  gastrointestinal  tract,  secrete  mucus. 

If  the  gland  tubules  become  dilated  as  the  result  of  the  accumula- 
tion of  the  secretion,  small  and  large  cysts  may  be  formed  which  com- 
municate with  each  other.  The  epithelium  lining  these  cysts  may 
proliferate  to  form  large  papillary  growths  which  completely  fill  the 
cavity  of  the  cyst  (papillary  cystocarcinomas  of  the  breast  and  ovary). 
Mucoid  degeneration  leads  to  the  formation  of  a  colloid  carcinoma 
(e.  g.,  in  the  breast),  just  as  in  cylindrical-cell  carcinomas. 

,  Predisposing  Causes. — Chronic  intianniiation,  contusions,  and  benign 
growths  (e.  g.,  fibroadenomas  of  the  breast)  are  regarded  by  many  as 
predisposing  causes.  The  etiological  relations,  however,  between  the 
lesions  above  mentioned  and  malignant  growths  are  based  upon  clinical 
observations  confined  almost  entirely  to  the  female  breast. 

Appearance  of  These  Growths. — The  clinical  appearance  of  the  carci- 
nomas occurring  in  the  different  glands  are  very  similar.  They  differ 
in   consistency,    the   scirrhus    forms   being   hard,    the   medullary    forms 

soft.  The  tumors  develop  as 
rtuind  nodules  which  invade 
the  normal  tissues  in  all  di- 
rections and  replace  them. 
The  nodules  become  fused 
with  the  adjacent  tissues. 
The  carcinoma  extends,  when 
it  reaches  the  surface  of  an 
organ,  to  the  adjacent  struc- 
tures (e.  g.,  a  carcinoma  of 
the  prostate  may  extend  into 
the  bladder  and  rectum). 
When  it  reaches  and  invades 
the  mucous  membrane  or  skin 
regressive  changes  soon  oc- 
cur, resulting  in  the  for- 
mation of  d(M»p  ulcers  and 
nodular  growths. 
The  female  breast  affo)'ds  the  best  examples  of  carcinomas  develop- 
uig  III  j-laiids.  Usually  the  nodule,  which  develops  without  symptoms, 
IS  accidentally  noticed.  Tt  appears  as  an  indurated  area,  the  size  of  a 
cherry,  within  tlie  substance  of  the  bivast.  The  boundaries  of  the 
nodule  are  indistinct,  and  it  is  firmly  adherent  to  the  surrounding  tis- 


I.A,-^l     (^iSnivKIHis). 


CARCINOMAS 


959 


sue.  If  the  tumor  lies  beneath  the  nipple  or  close  to  it,  the  latter  will 
be  somewhat  retracted  and  more  difficult  to  jn-asp  than  is  normally  the 
case,  as  the  processes  which  radiate  out  from  the  new  growth  hold  it 
fast.  While  the  induration,  M^hich  is  usually  associated  with  radiating 
pains,   enlarges,  the  skin   covering  it  becomes   dark   red   in   color,   and 

I 


Fig.  436. — Sectiox  through  a  Carcinoma  of  the  Breast,      a,   Maininary  glautl;  h,  car- 
cinoma; c,  subcutaneous  fat;  d,  retreated  nipple  which  is  adherent  to  the  new  growth. 

nodules  may  develop  in  it  and  processes  may  extend  into  the  subjacent 
fascia,  muscles,  and  even  to  the  thorax,  so  that  finally  the  tumor,  which 
in  the  beginning  could  be  displaced  with  the  breast,  becomes  firmly 
attached  and  can  no  longer  be  displaced  upon  the  pectoral  muscles  or 
ribs.  The  infiltrated  skin  ulcerates  and  the  tumor  grows  to  form  a 
large  mass  which  includes  all  of  the  breast  (medullary  form),  or  con- 
tracts to  form  a  nodular  mass  adherent  to  the  chest  wall,  which  under- 
goes here  and  there  regressive  changes,  ending  in  ulcer  formation  (scir- 
rhus).  Enlarged,  induratetl  lymph  nodes  are  usually  found  early  in 
the  disease  and  maj^  be  palpated  in  the  axillary  fossa.  Considerable 
ha'morrhage  may  occur  from  the  ulcers,  from  the  intercostal  and  inter- 
nal mammary  arteries.  I  hematogenous  metastases  develop  in  the  lungs, 
the  liver  and  other  viscera,  and  frequently  in  the  bones.  Death  finally 
occurs  as  a  result  of  an  increasing  cachexia  or  a  severe  haMuorrhage. 

The  clinical  symptoms  of  carcinomas  developing  in  glandulai-  organs 
naturally  depend  upon  the  position  of  the  growth.  The  symptoms  be- 
long to  special  surgery. 


960  DIFFERENT   VARIETIES   OF   TUMORS 

(d)  THE   CLINICAL   COURSE   OF   CARCINOMA 

The  clinical  course  is  very  varia])]e.  Local  invasion  and  destruction 
of  tissue,  the  development  of  lyniphojLi'enous  and  htematogenous  metas- 
tases, and  cachexia  are  common  to  all.  But  sometimes  the  clinical 
course  is  slow,  at  other  times  relatively  rapid.  Varying  energy  of 
growth,  the  location  of  the  tumor,  and  the  formation  of  metastases  are 
important  factors  in  determining  how  rapidly  or  slowly  the  disease  will 
progress.  The  causes  of  death  are  as  different  as  the  courses  of  the 
disease.  If  death  does  not  occur  from  some  secondary  disease,  such  as 
perforative  peritonitis  or  meningitis,  aspiration  pneumonia  or  hasmor- 
rhage,  it  is  usually  caused  by  exhaustion. 

Carcinomatous  Cachexia. — After  a  shorter  or  longer  period  the  con- 
dition of  the  patient  undergoes  very  significant  changes.  Rapid  and 
marked  emaciation,  loss  of  strength,  and  anamiia  combine  to  produce  the 
picture  of  carcinomatous  cachexia,  which  is  partly  due  to  the  absorption 
of  products  of  decomposition  from  the  tumor,  and  partly  to  secondary 
disturbances  (repeated  hannorrhages,  interference  with  the  taking  of 
food,  etc.)  and  to  the  development  of  metastases  in  important  viscera. 

Prognosis. — The  prognosis  of  cancer  is  very  unfavorable,  but  varies 
with  the  different  forms.  The  superficial  carcinomas  of  the  skin  are 
relatively  benign,  as  they  grow  slowly  and  at  first  are  localized,  forming 
metastases  late.  The  soft,  rapidly  infiltrating  forms,  especially  the  col- 
loid carcinomas  of  the  viscera  and  mucous  membranes,  belong  to  the 
worst  forms.  Carcinomas  developing  in  young  and  middle-aged  adults 
are  usually  more  malignant  than  those  developing  in  old  people.  The 
absolute  decrease  in  the  number  of  lymphatics  which  occurs  with  age 
may  account  for  the  les.'^ened  malignancy  of  these  growths  in  old  people. 

Duration.— T^sually  the  clinical  course  is  of  from  two  to  three  years' 
duration.  The  superficial  carcinomas  of  the  skin  and  the  contracting, 
cicatrizing  forms  are  the  only  ones  which  have  a  longer  course. 

Cures. — A  permanent  cure  can  only  be  expected  when  a  radical  oper- 
ation is  performed  early.  Statistics  concerning  permanent  cures  follow- 
ing radical  operations  differ  widely.  The  differences  in  statistics  being 
due  to  the  position  of  the  tumor,  the  extent  of  the  operation  required, 
the  technic  emi)l()yed,  the  skill  of  the  operator,  and  whether  the  case  came 
to  operation  early  or  late.  Statistics  are,  however,  encouraging,  as  they 
sliow  that  the  relative  number  of  cures  of  at  least  three  years'  duration 
have  steadily  incivased  with  improvement  in  diagnostic  methods  and  tech- 
nic. Even  if  there  are  recurrences  after  radical  operations,  the  length 
ol  liTr  of  (lie  patient  is  considei'ably  increased  by  such  a  j)rocedure. 

Radical  Removal. — (.)])erative  treatment  is  suited -only  for  those  cases 
iu  which  the  carcinoma  can  be  completely  removed  without  danger  to 


CAliCINUMAS  961 

life.  The  extent  of  the  primary  tumor,  the  amount  of  lymphatic  in- 
volvement, and  the  presence  of  or  suspicion  of  hiematoirenous  metas- 
tases should  be  considered  before  a  radical  operation  is  undertaken. 
Clinical  experience  has  shown  that  even  a  small  carcinoma  of  the  breast 
is  inoperable  when,  in  addition  to  the  involvement  of  the  axillary  lymph 
nodes,  there  is  involvement  of  the  supraclavicular  nodes,  for  it  has  been 
demonstrated  that  when  the  lymphogenous  metastases  are  so  extensive, 
recurrences  are  rapid,  even  after  radical  removal  of  the  breast  and  the  in- 
volved nodes  (von  Bergmann).  This  statement  has  been  substantiated 
by  the  later  investigations  of  Kiittner  in  von  Bruns's  clinic.  The  general 
condition  of  the  patient  should  also  be  carefully  considered  before  an 
operation  is  undertaken.  As  a  rule,  an  operation  should  not  be  under- 
taken if  the  tumor  has  already  reached  such  a  size  that  it  threatens  life. 

Recurrences. — Recurrences  following  operations  are  more  frequent 
in  the  tissues  surrounding  the  extirpated  lymph  nodes  than  in  those 
about  the  primary  tumor.  This  is  easily  explained,  for  in  spite  of  the 
removal  of  the  enlarged  lymph  nodes,  together  with  the  fat  and  fascia 
surrounding  them,  small,  imperceptible  lymph  nodes  may  be  left  behind 
Avhich  already  contain  carcinoma  cells.  Local  recurrences  follow  most 
frequently  those  carcinomas  which  send  out  continuous  or  interrupted 
processes  into  the  lynqjhatic  vessels,  which  extend  well  beyond  the  appar- 
ent boundaries  of  the  primary  tumor.  Recurrences  about  the  scar,  which 
occur  after  long  intervals,  may  be  regarded  as  new  tumors,  especially 
if  there  are  preexisting  lesions  (e.  g.,  a  leucoplakia)  which  favor  the 
development  of  carcinoma.  Nothing  definite  can  be  said  concerning 
the  so-called  implantation  recurrences  which  are  supposed  to  follow  the 
implantation  of  carcinoma  cells  in  the  wound  during  an  operation.  In 
these  cases  the  transmission  of  carcinoma  cells  through  the  lymphatics 
jnust  be  dt^finitely  (excluded  before  an  opinion  can  be  given. 

Causes  of  Carcinoma. — Nothing  definite  is  known  concerning  the  caiLse 
of  carcinoma.  The  principal  theories  have  already  been  discussed  in  the 
general  discussion  of  tumors. 

The  fact  that  carcinomas  not  infrequently  develop  from  wounds  and 
scars,  from  benign  new  growths  and  chronically  inflamed  tissues  is  used 
by  the  defendants  of  Virchow's  theory  of  chronic  irritation  to  show 
that  the  latter  may  produce  changes  in  the  cells  which  result  in  unre- 
stricted proliferation.  Congenital  carcinomas  and  the  development  of 
a  carcinoma  from  demonstrable  embryonal  rests,  both  of  which  are  rare, 
also  the  occurrence  of  a  S(|uam()us-cell  carcinoma  in  mucous  membranes 
composed  of  colunniar  cells  have  been  used  to  sul)stantiate  Cohnheim's 
theory  that  tumors  developed   from  displaced  emliryonal  rests. 

According  to  Ribbert,  the  general  cause  of  carcinoma  formation  is 
the  displacement  of  small  islands  of  epithelium  from  their  normal  con- 


962  DIFFERENT   VARIETIES   OF   TUMORS 

nections,  the  displacement  following  tlie  proliferation  of  the  connective 
tissue,  which  may  be  caused  by  a  lunnber  of  different  agents. 

The  parasitic  theory  concerning  the  origin  of  carcinoma  has  won 
many  friends.  This  theory  rests  partly  upon  an  analogy  between  dis- 
eases which  are  undoubtedly  of  an  infectious  origin  and  carcinomas, 
and  partly  upon  clinical  observations  that  carcinomas  occur  most  fre- 
quently upon  parts  exposed  to  irritation  (e.  g.,  about  the  orifices  of  the 
body,  in  narrow  or  tortuous  parts  of  the  gastrointestinal  tract),  in  ulcers 
or  chronically  inflamed  tissues,  in  man  and  wife  or  many  members  of  the 
same  family.  These  facts  observed  clinically  may  be  most  easily  explained 
by  assuming  an  infectious  origin.  But  the  structures  which  have  been 
regarded  as  parasites  have  been  proven  by  later  investigations  to  have 
been  inclusions  of  epithelial  cells  or  leucocytes.  The  peculiar  and  differ- 
ent appearance  of  the  cell-inclusions  are  dependent  upon  the  extent  of 
the  regressive  changes  in  the  latter.  The  microorganisms  which  have 
been  found  and  cultivated  cannot  be  regarded  as  the  cause  of  carcinoma. 
Besides,  the  histology  of  certain  forms  of  carcinoma  and  the  way  in  which 
they  develop  are  important  arguments  against  the  parasitic  theory. 

Heredity. — The  question  of  heredity  is  still  unsettled,  as  it  is  dif- 
ficult to  estimate  the  value  and  accuracy  of  statistics  regarding  it.  Clin- 
ically, it  is  quite  striking  that  many  members  of  the  same  family  may 
apparently  inherit  the  tendency  to  carcinoma  formation  and  that  the 
same  organ  may  be  primarily  involved. 

Literature. — Ausfiihrliehe  Literaturangaben  bei  Borst.  Die  Lehre  von  den 
Geschwiilsten.  Wiesbaden,  1902,  II,  p.  966. — v.  Bergmann.  Das  lupusahnliche 
Karzinom.  Handb.  der  prakt.  Chir.,  2.  Aufl.,  Bd.  1,  p.  47. — Borrmann.  Das  Wachstum 
und  die  Verbeitungsweise  des  Magenkarzinoms.  Kitteil.  aus  d.  Grenzgeb.,  Bd.  1, 
Suppl.,  1901 ; — Die  Entstehung  und  das  Wachstum  des  Hautkarzinoms,  nebst  Berne rk- 
ungen  iiber  die  Entstehvmg  der  Geschwiilste  im  allgemeinen.  Zeitschr.  f.  Krebsforsh., 
Bd.  2,  1904; — Statistik  und  Kasuistik  iiber  290  histol.  untersuchte  Hautkarzinome. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  76,  1905,  p.  404. — Cocnen.  Zur  Kasuistik  und  Histologie 
des  Ilautkrebses.  Arch.  f.  klin.  Chir.,  Bd.  78,  1905,  p.  801.— i/awser.  Das  Zylinder- 
epithelkarzinom  des  Magcns  und  des  Dickdarms.  Jena,  1890. — Heimann.  Die  Ver- 
breitungsweise  der  Krebserkrankung.  Arch.  f.  klin.  Chir.,  Bd.  57,  1898,  p.  911. — 
Krompecher.  Der  Basalzellenkrcbs.  Jena,  1903. — Kuttner.  Welche  Aussichten  bietet 
die  Operation  des  Mammakarzinoms  beit  vergrcisserten  Supraklavikulardriisen?  Beitr. 
z.  klin.  Chir.,  Bd.  36,  1902,  p.  531.— Milner.  Gibt  es  "Impfkarzinome"?  Arch.  f. 
klin.  Chir.,  lid.  74,  1904,  p.  669. — Fr.  Midler.  Stoffwcchseluntersuchungen  bei  Krebs- 
kraiikcn.  Zeitschr.  f.  klin.  Med.,  Bd.  16,  1889,  p.  496. — Orth.  Die  Morphologic  der 
Krcl)sc  und  die  parasitiire  Theorie.  Berl.  klin.  Wochenschr.,  1905,  p.  281. — Petersen. 
Hoitrage  zur  Lehre  vom  Karzinom.  Beitr.  z.  klin.  Chir.,  Bd.  32,  1902,  p.  543; — 
Ucbcr  Ilcilungsvorgangc  im  Karzinom  (Riesenzellen).  Ibid.,  Bd.  34,  1902,  p.  682. — 
liihbert.  Gcschwulstlchre.  Bonn,  1904,  p.  459; — Die  Entstehung  des  Karzinoms. 
Bonn,  1905; — Beitr.  zur  Entstehung  d.  Geschwulste.  Bonn,  1906. — v.  Volkmann. 
Meber  den  primjiren  Krebs  der  Extremitaten.  v.  Volkmann's  Samml.  klin.  Vortr., 
1889,  Nos.  334-335. 


KND()THELIAL   TUMORS  963 


E.     ENDOTHELIAL    TUMORS 

ENDOTHELIOMAS 

Von  Recklinghausen  (1862)  was  fii-st  to  reeouni/e  that  endothelial 
cells  composed  the  proliferating'  part  of  these  tniiioi-s.  This  fact  has  been 
especially  emphasized  by  Koster.  The  classification  of  these  tumors,  in 
spite  of  the  amount  of  investigation  that  has  been  devoted  to  them,  is 
still  a  mooted  (piestion. 

Nature  of  Endothelium. — The  intimate  relationship  between  endo- 
thelium and  connective  tissue  (His)  does  not  permit  one  to  draw  a 
sharp-and-fast  line  of  distinction  between  these  tumors  and  sarcomas. 
Plistologically,  endotheliomas  resemble  some  epitheliomas  so  closely, 
especially  those  in  which  there  is  the  formation  of  gland  tubules,  that 
it  is  impossible  to  give  any  opinion  acceptable  to  all  pathologists  as  to 
the  nature  of  the  cells  (e.  g.,  Krompecher's  carcinoma  basocellulare,  p. 
938 ;  mixed  tumors  of  the  salivary  glands,  p.  971 ;  cholesteatomas,  cylin- 
dromas). Besides,  there  is  no  uniformity  of  opinion  among  embryolo- 
gists  and  histologists  as  to  the  classification  of  endothelium,  the  latter 
being  regarded  by  some  as  connective  tissue,  by  others  as  epithelium. 
Clinically  these  tumors  have  certain  peculiarities. 

It  is  impossible  to  make  a  positive  clinical  diagnosis  of  an  endo- 
thelioma. The  microscope  must  decide  the  nature  of  the  tumor.  Even 
an  experienced  pathologist  may  have  great  difficulty  in  making  a  micro- 
scopic diagnosis  and  differentiating  a  tumor  of  this  character  from  cer- 
tain forms  of  carcinoma,  sarcoma,  and  adenoma. 

It  is  customary  to  divide  these  tumors  into  lymphangio-cndothelio- 
mas,  hcemangio-eiidotJieliomas,  and  into  special  forms,  such  as  peritheli- 
omas, and  endotheliomas  of  the  dura  mater  (psammomas). 

Lymphangio-endotheliomas. — Lymphangio-endotheliomas  develop  from 
the  endothelium  lining  the  tissue  spaces  and  lymphatic  vessels.  These 
tumors  are  composed  of  columns  of  cells  which  correspond  to  the  course 
of  the  lymphatics.  The  cells,  which  have  a  tubular  or  solid  arrange- 
ment, are  flat,  cubical,  or  columnar.  The  three  varieties  may  be  foimd 
in  different  parts  of  the  tumor  or  combined  in  the  same  field.  The  cell 
columns  are  enlarged  at  the  nodal  points,  and  the  cells  composing  them 
may  be  concentrically  arranged.  According  to  Borst  the  cell  columns, 
which  differ  in  size,  have  a  delicate  linear  arrangement  and  are  lined  by 
two  layers  or  a  single  layer  of  cells,  resembling  very  closely  the  histo- 
logical picture  presented  by  proliferating  lymphatic  vessels.  These 
tubules  may  dilate  to  form  cysts.     If  papillary  growths  then  develop, 


964 


DIFFERENT   VARIETIES   OF   TUMORS 


the  tumor  may  be  mistaken  for  a  cavernous  or  cystic  lympliangioma  or 
for  a  papillary  cystadenoma  (e.  g.,  of  the  sweat  glands). 

Stroma. — The  character  of  the  connective-tissue  stroma  varies.  It 
may  be  very  cellular,  mucoid,  or  fibrous.     Probably  a  metaplasia  of  the 

stroma  into  cartilage,  oc- 
\S\  casionally  even  into  bone, 
occurs,  the  presence  of 
cartilage  and  bone  in 
mixed  tumors  of  the  pa- 
rotid and  related  forms 
of  endotheliomas  being 
explained  in  this  way 
(p.  974). 

Most  Common  Sites  for 
Development.  —  Lijmpli- 
071  g io  -  endotheliomas  of 
the  skin  and  subcutane- 
ous tissues,  especially  of 
the  face,  appear  as  cir- 
cumscribed, encapsulated 
nodules  or  non-encapsu- 
lated growths  which  are 
sometimes  regarded  as 
sarcomas,  sometimes,  es- 
pecially when  ulcerated,  as  carcinomas  of  the  skin.  They  grow  slowly, 
but  rarely  forming  metastases,  and  therefore  are  to  be  regarded  as  rela- 
tively benign  tumors.  According  to  Tanaka,  the  lymph  nodes  when  in- 
volved are  of  a  soft,  fluctuating  consistency,  and  are  not  adherent  to 
the  sun-ounding  tissues. 

Similar  tumors,  which  have  been  regarded  as  lymphangio-endotheli- 
omas,  occur  in  the  different  viscera,  in  the  membranes  of  the  central 
nervous  system,  in  the  bon(\s,  the  ovary  and  testicle,  and  in  the  salivary 
glands.  The  latter  are  sometinu's  regarded  as  mixed  tumojs  (Wilms), 
and  .sometimes  as  fibroepithclial  growths  (Ribbert).  As  a  result  the 
group  of  endotheliomas  has  been  considerably  reduced.  These  tumors 
are  usually  encapsulated. 

EikIoIIk lionids  of  Pleura  and  Peritoneum. — Endotheliomas  of  the 
pleura  and  ix-riloiieutii  are  rare.  They  produce  a  diffuse,  thick  infiltra- 
tion of  the  membi-aue  involved,  and  fr('(|ueiitly  foi-m  metastases.  Endo- 
theliomas of  the  pleura  mny  also  produce  large  nodular  tumors  which 
invade  the  linig.  J)epending  ui)()n  the  view  held  concei'uing  the  origin 
and  uiiture  of  the  e(41s  covering  tli(^  serous  membranes,  these  tumors 
are  classified  as  endotheliomas  or  carcinomas. 


Fig.  437. — Lymphangio-endothelioma  of  the   Skix. 


ENDOTHELIAL  TUMORS 


965 


Hmmangio-endothcJionuts.  —  Haimangio-endotheliomas  develop  from 
the  endothelium  of  blood  vessels. 

The  proliferating  capillaries  and  small  vessels  which  compose  these 
tumors  are  lined  or  filled  with  tall,  actively  proliferating  endothelial 
cells.  They  appear  upon  microscopic  examination  as  glandlike  tubules 
or  solid  cell  columns  w'hich  branch  repeatedly  and  communicate  with 
each  other.  If  the  proliferating  endothelium  is  cubical  or  cylindrical, 
the  tumor  can  only  be  differentiated  from  a  new  growth  developing 
from  a  gland  by  the  presence  of  blood  in  the  lumina  of  the  vessels. 

Ilffimangio-endotheliomas  usually  grow  slowly,  are  circumscribed,  and 
have  but  little  tendency  to  invade  the  surrounding  tissues  and  form 
metastases.  They  have  been  observed  in  the  different  viscera  and  in 
the  bones,  occurring  in  the  latter  also  as  multiple  growths  (Fritz  Konig, 
Narath).  These  tumors  resemble  upon  section  ha^mangiomas  or  very 
vascular,  soft  sarcomas.  Endotheliomas  occurring  in  bone  produce  a 
pressure  atrophy  and  expansion  of  the  cortex.  They  are  so  vascular 
that  they  often  give  rise  to  symptoms  resembling  those  of  an  aneurysm. 


Fig.  438. — H.EMANC.io-ExnoTHELiOMA  of  the  Kidney,  a,  Blood  vessels  containing  blood; 
b,  blood  vessels  filled  with  proliferating  endothelial  cells.  (From  Ziegler's  General 
Pathology.) 

reritheliomas. — Peritheliomas  are  a  variety  of  ha^mangio-endotheli- 
omas;  sometimes  they  are  regarded  as  lymphangio-endotheliomas. 

These  tumors  may  develop  from  the  adventitial  cells  of  the  blood 
vessels,  which  apparently  are  very  similar  to  endothelial  cells,  or  from 
the  endothelium  of  the  perivascular  lymphatics.     The  tumor  tissue  is 


966 


DIFFERENT   VARIETIES  OF   TUMORS 


composed  of  dilated  capillaries,  M'liich  are  surrounded  by  a  wide  zone  of 
cells  of  different  forms.  The  cell  mantles,  or,  more  correctly,  the  cell 
cylinders,  containing  the  blood  vessels  are  very  sharply  differentiated 
from  the  poorly  developed  connective-tissue  stroma. 

The  vessels   surrounded   by  the   cells  have   a  cirsoid   arrangement, 
branch  frequently,  and  give  rise  to  a  very  characteristic  histological  pic- 


FiG.  439. — P?:i!rrHF:i,ioMA  of  the  Thyroid  Gland,  a,  Section  through  a  vessel;  h,  peri- 
vascular cylindrical  cells  with  many  mitoses;  c,  granular  masses  and  cells  between  the 
cell  colunuis.     (From  Ziegler's  General  Pathology.) 

ture.  The  latter  is  so  characteristic  that  Waldeyer  has  called  these 
tumors  plexiform  angiosarcomas;  Kolaczek,  angiosarcomas.  It  seems 
best  to  avoid  the  use  of  these  terms,  however,  as  the  tumors  might 
then  be  confused  with  very  vascular  sarcomas,  which  might  also  be 
called  angiosarcomas,  or,  better,  telangiectatic  or  cavernous  sarcomas 
(Borst). 

Sarcomas  in  which  the  proliferation  of  perivascular  cells  is  pro- 
nounced reseml)le  peritheliomas  very  closely,  when  the  cell  cylinders 
are  fused.  If  hyaline  degeneration  occurs  and  the  vessels  become  oblit- 
erated, the  tumor  resembles  a  cylindroma. 

Peritheliomas  are  found  mo.st  fre(|uently  in  the  brain  and  in  the 
membranes  surrounding  it.  They  appear  as  circumscribed  nodules  or 
as  diffuse,  even  multiple,  infiltratioTis.  They  are  also  found  in  the  sub- 
eiitaucous  tissue,  especially  in  the  subcutaneous  tissues  of  the  cheeks  and 
lowcc  lip,  ill  tile  bones,  nuiscles,  and  different  viscera.    The  encapsulated 


ENDOTHELIAL   TUMORS 


967 


tumors  developing  from  tlie  carotid  gland  and  situated  at  llic  bifurca- 
tion of  the  conniion  carotid  are  lusually  peritheliomas. 

Peritheliomas  are  relatively  benign  tumors. 

Psammomas. — Tumors  of  the  dura  mater  form  a  special  class  of  endo- 
theliomas. They  contain  small  calcjum  granules  which  resemble  sand, 
such  as  normally  occurs  in  the  pineal  gland  and  upon  the  inner  surface 
of  the  dura.  The  term  psiunmoma  was  ai)plied  to  these  tumors  by 
Virchow. 

These  tumors  develop  from  the  endotlielial  cells  covering  the  inner 
surface  of  the   dura,   and   appear  as  grayish   red,   circumscribed,    firm, 


Fig.  440. — Ps.wimoma  of  the  Dura  Situatkh  upon  the  Posterior  Surface  ok  the  Right 
Petrous  Bone  and  Producing  a  Depression  in  the  Flocculus,  the  Corhespond- 
iNG  Superior  Cerebellar  Peduncle  and  the  Pons.  The  trunk  of  the  fifth  nerve  (o) 
runs  through  the  tumor  mass  (6).  The  facial  and  auditory  nerves  lie  upon  the  outer 
side  of  the  tumor  and  are  fused  with  its  capsule.  The  only  symptoms  produced  bj'  this 
tumor,  which  was  almost  as  large  as  a  walnut,  was  severe  trifacial  neuralgia.  The 
patient,  a  woman  seventy-three  years  of  age,  tlied  following  the  removal  of  the  Gasserian 
ganglion  and  the  tumor  was  found  during  the  post-mortem  examination.      (Lexer.) 


hemispherical  tumors.  Tluy  are  attached  to  the  dura  by  a  broad  base 
or  short  pedicle,  and  produce  a  depression  in  the  surface  of  the  brain, 
being  separated  from  the  latter  by  a  vascular  capsule.  They  usually 
occur  as  single,  more  rarely  as  multiple  growths,  and  are  found  more 


968 


DIFFERENT   VARIETIES  OF   TUMORS 


frequently  upon  the  upper  than  upon  the  lower  surface  of  the  brain. 
These  tumors  differ  in  size.  Only  the  larger  tumors,  the  size  of  a  walnut 
or  apple,  produce  symptoms,  which,  of  course,  are  those  of  a  brain 
tumor.  The  smaller  tumors,  often  no  larger  than  a  pinhead,  produce 
no  symptoms  and  are  usually  accidentally  discovered  during  post-mor- 
tem examinations.  Usually  they  grow  slowly.  The  cellular  forms  may 
develop  relatively  rapidly  and  rupture  through  the  dura  mater  and 
bone. 

These  tumors  do  not  form  metastases.  The  dangers  associated  with 
them  depend  altogether  upon  the  position  of  the  tumor. 

The  relation  between  the  parenchyma  and  stroma  varies  in  differ- 
ent tumors.  The  cells  composing  the  former  are  flat  or  polymorphous 
and  are  arranged  in  groups  or  columns.  These  groups  or  columns 
are  surrounded  by  connective-tissue  trabecule  which  contain  few  or 
many  cells.  Among  the  endothelial  elements,  which  under  the  micro- 
scope appear  in  well-deflned  alveoli  or  columns,  may  be  seen  varying 
numbers  of  stratified  bodies  composed  of  cells  concentrically  arranged. 

These  undergo  calcifica- 
tion and  become  trans- 
formed in  the  white  bodies 
resembling  grains  of  sand. 
Connective -tissue  bundles 
may  also  undergo  hyaline 
degeneration  and  calcifi- 
cation. 

Similar  tumors'  also  oc- 
cur within  the  orbit,  devel- 
oping in  the  dural  sheath 
of  the  optic  nerve  (Rib- 
bert).  They  are  also  found 
in  the  pia  mater,  the  pineal 
gland,     and     the     chorcud 

m-\-m:v  '  •'^"^'•^   •    ■  v-v  '**  I  i>     - "  ■i'      plexus.      Multiple    tuuiors 

^yu^t    ''  ■■  ••     ..  !>''"  .'■■■  ^ •  ..'  /:at^r^.»'"-  of  this  character  are  occa- 

I'Hi.  441.— (•V1.1NJ.H..MA  OF  TiiK  ouiuT.  sloually  fouud  in  tlie  peri- 

toneum  (Boi'st). 

Cylindroma.  — Thv  eyliiidi-oiiias,  fii-st  dcscfibcd  by  P.ilh-oth  in  1856, 
and  regarded  by  Kiister  as  endotlielial  growths  willi  liyaline  degen- 
eration of  tlie  cell  columns,  are  classified  by  many  authors  with  endo- 
theliomas. 

The  small,  glassy,  hyaline  bodies  of  I'ound,  bidboiis,  cordlike  or  cylin- 
drical foi-ii!  with  iiimieroiis  braru'Jies  and  bulbous  expansions,  which  may 
be  easily  isolalcd  Ifom  the  cut  surface  of  a  fresh  tumor,  are  character- 


ENDOTHELIAL   TUMORS  969 

istie.  The  histological  i)i('tnro  is  (|iiite  characteristic,  as  these  giasslike 
bodies  are  surrounded  by  a  broad  mantle  of  cells.  If  there  are  no  cell 
rests  or  fibrillie  Avithin  the  bodies  above  mentioned,  they  appear  as 
lumina  of  large  vessels. 

A  similar  histological  picture  may  be  produced  in  a  number  of  dif- 
ferent forms  of  tumors  by  hyaline  degeneration  of  the  cells  or  by  secre- 
tion poured  out  from  them.  For  these  reasons  a  7i umber  of  patholo- 
gists (Ziegler,  Orth,  Lubarsch)  are  unwilling  to  place  cylindromas  in 
a  separate  and  distinct  class. 

A  similar  histological  picture  is  presented  by  vascular  sarcomas  after 
hyaline  degeneration  of  the  cells  and  o])literation  of  the  lumina  of  the 
vessels,  by  adenomas  and  carcinomas  after  the  secretion  of  a  hyaline  ma- 
terial and  its  accumulation  in  the  glandlike  tubules,  or  between  the  cells 
forming  a  solid  column.  One  can,  therefore,  speak  of  a  sarcoma,  car- 
cinoma, or  adenoma  cylindromatosum. 

The  changes  above  described  occur  most  frequently  in  endotheliomas 
and  peritheliomas.  Borst  regards  these  two  forms  as  true  cylindromas. 
Ribbert  also  places  them  in  a  separate  group,  but  regards  them  not  as 
endothelial  new  growths,  but  as  fibroepithelial  tumors,  believing  that 
they  develop  from  nuicous  or  closely  allied  glands. 

These  tumors  have  a  slow  growth,  are  encapsulated,  and  often  may 
be  recognized  upon  gross  examination  by  the  cavities  containing  hyaline 
masses.  They  rarely  invade  the  surrounding  tissues,  and  are  rarely  fol- 
lowed by  metastases.  They  may  be  regarded  as  benign  tumors.  The 
hyaline  changes  occur  partly  within  the  endothelial,  or,  according  to 
Ribbert,  epithelial  cell  colunuis,  parti}'  within  the  connective-tissue  stronui 
lying  between  them. 

These  tumors  develop  most  frequently  in  the  orbit,  the  salivary 
glands,  the  palate,  the  floor  of  the  mouth,  the  antrum  of  Highmore,  and 
the  nose.  Sometimes  they  are  found  in  the  skin,  the  membranes  of  the 
brain  and  cord,  in  the  peritoneum,  in  muscles  and  bone. 

They  have  no  characteristics  which  make  a  positive  clinical  diagnosis 
possible.  Developing  in  the  salivary  glands  or  palate,  they  resemble 
closely,  clinically,  encapsulated  adenomas  or  mixed  tumors.  If  they  ex- 
tend from  the  orbit  into  the  nose,  the  antrum  of  Highmore,  or  the  I'l-ontal 
sinus,  they  may  resemble  a  carcinoma  or  sarcoma. 

Treatment. — The  treatment  of  all  the  tumors  of  the  endotlu'lial  group 
consists  of  removal.  If  they  are  encapsulated  they  may  ))e  enucleated. 
If  they  have  no  capsule  and  have  invaded  the  neighboring  tissues,  they 
should  be  treated  as  malignant  tumors. 

Literature. — Billroth.     TTntersuchunp:en    iiber   die   Entwicklung   dor   Blutgefiisse 
nebst  Beobachtungen  aus  der  Berliner  Klinik.     Berlin,  18r)G,  Die  Zylindergeschwulst, 
p.   55. — Borst.     Die  Lehre  von  den  Geschwiilsten.     Wiesbaden,    l',)02,   II,   p.   953. — 
62 


970  DIFFERENT   VARIETIES   OF  TUMORS 

Burkhardt.  Saikome  unci  Eudothelioine  nach  ihrem  path.-anat.  iind  klin.  Verhalten. 
Beitr.  z.  klin.  Cliir.,  Bd.  36,  1902,  p.  1. — Hildebrand.  Ueber  Resektion  des  Penis  wegen 
eines  Endothelioma  intravasculare.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  48,  1898,  p.  209. — 
Hinsbcrg.  Die  klinische  Bedeutung  der  Endothelionie  der  Gesichtshaut.  Beitr.  z.  klin. 
Chir.,  Bd.  24,  1899,  p.  275. — -Fritz  Konig.  Ueber  multiple  Angiosarkonie.  Arch.  f.  klin. 
Chir.,  Bd.  59,  1899,  p.  600. — Koster.  Kankroid  mit  hyaliner  Degeneration  (Cylindroma 
Billroths).  Virch.  Arch.,  Bd.  40,  1867,  p.  4GS.—Mulert.  Ein  Fall  von  nuiltiplen 
Endotheliomen  der  Kopfhaut.  I.-D.,  Rostock,  1897. — -Narath.  Pulsierendes  Angio- 
endotheliom  des  Fusses.  Chir.-Kongr.  Verhandl.,  1895,  II,  p.  427. — Nasse.  Die 
Geschwiilste  der  Spiecheldriisen  und  verwandte  Tumoren  des  Kopfes.  Arch.  f.  klin. 
Chir.,  Bd.  44,  1892,  p.  233. — v.  Recklinghausen,  v.  Grafes  Archiv  fiir  Ophthalmologic, 
Bd.  10,  Abt.  2,  1864,  p.  62. — Ribbert.  Geschwulstlehre.  Bonn,  1904.— Tanaka.  Ueber 
die  klinische  Diagnose  von  Endotheliomen  und  ihre  eigentiimliche  Metastasenbildung. 
Deutsche  Zeitschr.  f.  Chir.,  Bd.  51,  1899,  p.  209.— Volkmann.  Ueber  endotheliale 
Geschwiilste,  zugleich  ein  Beitrag  zu  den  Speicheldriisen-  und  Gaumentumoren.  Deutsch. 
Zeitschr.  f.  Chir.,  Bd.  41,  1895,  p.  1. 


F.    MIXED    TUMORS 

Definition. — By  the  term  mixed  tumor  is  usually  understood  a  tumor 
which  is  composed  of  different  tissues.  They  are  distinguished  from 
the  combined  forms  of  connective-tissue  tumors,  such  as  fibrolipomas, 
osteochondrosarcomas,  lymphangiolibromas,  etc.,  and  also  from  the  fibro- 
epithelial  growths  in  which  the  epithelium  resembles  mucous  membrane, 
skin,  or  glandular  epithelium. 

]\Iixed  tumors  form  a  distinct  group  which  vary  a  great  deal  in 
their  histological  characteristics.  As  there  are  so  many  transitional 
forms,  a  division  into  other  groups  is  necessary.  If  the  classification 
is  based  upon  the  structure,  which  is  sometimes  simple,  sometimes  com- 
plicated, and  at  other  times  highly  organized,  the  three  following  forms 
may  be  differentiated : 

1.  Simple  mixed  tumors  of  different  organs. 

2.  Teratoid  tumors  with  two  varieties: 

(a)  Complicated  dermoid  cysts  of  the  ovary  and  testicle  (cystic 
embryomas  of  Wilms). 

(&)    Teratoid  mixed  tumors  (eml)ryoid  tumors  of  Wilms). 

3.  Teratomas. 

CHAPTER    I 

siMPiiE  mixi:d  tumors 

Nature  and  Origin. — These  tumors,  varying  so-  nmch  in  structure, 
have  attracted  the  attention  of  a  number  of  investigators,  but  even  at 


SIMPLE   MIXED   TUMORS 


!)71 


tlie  present  time  tlu>re  is  no  iinii'orniity  of  opinii^n  concerniiiy  thfir 
nature  and  origin.  Some  pathologists  believe  that  they  are  the  result 
of  metaplasia  or  of  a  tumorlike  metamorphosis  of  adult  tissues;  while 
others  think  that  they  develop  from  displaced  pieces  of  germinal  tissue, 
supporting  Cohnheim's  theory  eonecrniiig  the  cause  of  tumor  formation. 

The  latter  view  appears  to  Wilms  to  be  the  more  plausible.  Accord- 
ing to  him  these  tumors  develop  from  undifferentiated  germinal  tissue 
which  was  displaced  very  early  in  fecial  life  and  is  potentially  able  to 
reproduce  any  of  the  tissue  normally  found  in  the  part  from  which  it 
was  displaced. 

The  group  of  simple  mixed  tumors  comprises  tumors  of  the  salivary 
glands,  breast,  and  of  the  urogenital  system.  Some  of  these  tumors 
are  well  known  clinically.  Within  this  group  of  simple  tumors  are 
some  which  are  relatively  complicated.  It  is  impo.ssible  to  make  a  sharp 
distinction  between  them  and  fibroepithelial  growths  on  the  one  hand 
and  teratoid  tumors  on  the  other. 

Mixed  Tumors  of  Salivary  Glands. — ]\Iixed  tumors  of  the  salivary 
glands  are  found  most  frequently  in  the  parotid,  more  rarely  in  the 
other  salivary  glands. 
They  appear  as  well- 
circumscribed  growths 
which  may  develop  at 
any  age,  being  most  com- 
mon in  the  second  and 
third  decennia.  These 
tumors  grow  very  slow- 
ly, cases  having  been 
observed  in  which  the 
growth  has  existed  from 
twenty  to  forty -five 
years  without  enlarging 
to  any  great  extent. 
Occasionally,  however, 
they  assume  rapid 
growth  and  reach  con- 
siderable size  (as  large 
as  a  man's  head).  Usu- 
ally they  are  encapsu- 
lated and  sharply  de- 
lined  against  the  sur- 
rounding tissue,  ai-e  displaceable  upon  tlie  sul),jaeent  tissues,  and  covei'cd 
by  normal  skin,  which  may,  however,  be  tense  and  thin  if  the  tumor 
is  large.     The  surface  of  such  a  tumor  is  usually  nodular,  the  nodules 


Fig.  442. — Mim:i>  'J'umor  of  thf,  I'ahotii)  (Jland. 


972 


DIFFERENT   VARIETIES   OF  TUMORS 


being  large.  The  consistency  is  usually  hard,  but  frequently  in  some 
parts  of  the  tumor  soft,  even  pseudo-fluctuating  areas  may  be  found 
between  the  firm,  resistant  parts. 

The  completely  encapsulated  growths  lie  between  the  lobules  or  upon 
the  surface  of  the  parotid  gland,  in  which  they  produce  a  bed  by  their 
expansive  growth.  At  times  a  tumor  is  attached  to  the  gland  by  a 
pedicle.  Occasionally  nuiltiple  tumors  are  found  within  the  salivary 
glands. 

Position. — If  the  tumors  develop  in  the  anterior  part  of  the  parotid 
gland,  they  lie  just  in  front  of  the  ear,  between  the  zygoma,  the  ante- 
rior border  of  the  masseter  muscle  and  mandible,  while  if  they  develop 
from  the  lower  and  posterior  part  of  the  gland  they  surround  the  lobule 
of  the  ear  which  they  elevate  and  displace. 

Symptoms. — Symptoms  are  produced  by  the  larger  tumors  only. 
Most  frequently  the  symptoms  are  facial  paralysis  and  partial  deaf- 
ness, the  latter  being  due  to  narrowing  of 
the  external  auditory  canal.  Usually  these 
tumors  cause  no  pain,  and  it  is  easily  un- 
derstood why  the  majority  of  the  patients 
seek  surgical  aid  so  late.  On  an  average,  pa- 
tients carry  these  tumors  eight  years  before 
they  seek  surgical  aid,  notwithstanding  the 
great  disfigurement.  Surgical  aid  is  usually 
sought  because  of  facial  paralysis  or  rapid 
increase  in  the  size  of  the  growth. 

Malignant  Degeneration  and  Metastases. — 
The  submaxillary  tumors  develop  in  the  sub- 
maxillary region.  If  they  are  situated  in  the 
median  part  of  the  gland  they  may  project 
into  the  floor  of  the  mouth.  Slow  growth, 
encapsulation,  and  mobility  of  these  tumors 
indicate  their  benign  character.  A  malignant 
change  is  indicated  by  rapid  growth  and  by 
the  invasicm  of  the  surrounding  tissue,  following  the  rupture  of  the 
growth  through  a  part  of  its  connective-tissue  capsule.  Kiittner  esti- 
mates that  about  eleven  per  cent  of  the  mixed  tumors  which  occur  in  the 
submaxillary  gland  become  malignant.  Lymphogenous  and  hamiatoge- 
nous  metastases  then  develop  as  in  carcinomas  and  sarcomas,  depending 
upon  whether  the  mixed  tumor  imdergoes  carcinomatous  or  sarcomatous 
dcgenci-ation,  while  the  primai-y  tumor  hecoines  so  extensive  that  it 
hecdiiies  iiiopernhle  and  breaks  through  the  skin,  forming  deep  ulcers. 
Diagnosis. — The  diagnosis  is  ])ased  upon  the  position  of  the  tumor, 
the  slow  growth,  nodular  form,  uneven  consistency,  and  encapsulation. 


Fig.  443. — liKNu.N  Mixed  Tu- 
Moii  OF  THE  Soft  Palate. 


SIMPLE   MIXED   TUMORS  973 

A  mixed  tumor  which  lias  iindcroojie  malifiiiant  degeneration  can  bo 
differentiated  from  a  carcinoma  or  sarcoma  only  by  the  prcvions  history 
of  a  preexisting  tumor  Avhicli  has  been  noted  for  some  time,  and  the 
uneven  consistency.  If  the  tumor  is  small,  tuberculous  lymph  nodes 
and  lipomas  must  also  be  considered  in  making  a  differential  diagnosis. 
Cystic  mixed  tumors  may  easily  be  confused  with  retention  cysts,  which 
are  not  rare,  especially  in  the  parotid  gland. 

Trealment. — The  indication  for  treatment  is  complete  removal.  En- 
capsulated tumors  of  the  parotid  gland  can  usually  be  removed  without 
injuring  the  facial  nerve.  If  the  tumor  is  situated  in  the  sul)niaxi]lary 
gland,  the  latter  should  be  removed  with  the  tumor.  Kecurrences  are 
rare.  They  may  develop  from  portions  of  the  tumor  which  were  left 
behind  during  the  operation  or  from  other  small  tumors  within  the 
gland.  If  the  tumor  has  become  malignant,  the  dissection  should  be  car- 
ried well  into  healthy  tissues.  No  effort  should  be  made  to  spare  the 
facial  nerve  when  a  tumor  which  has  undergone  malignant  changes  is 
situated  in  the  parotid  gland.  Recurrences  develop  early  even  after  the 
most  radical  procedures,  and  the  prognosis  is  bad  if  the  tumor  has 
already  become  malignant. 

Mixed  Tumors  in  Other  Parts  of  the  Head. — Similar  tumors,  but  of  a 
simpler  structure,  are  also  found  adjacent  to  the  parotid  and  sub- 
maxillary glands  in  the  cheek  (developing  from  accessory  salivary 
glands),  in  the  upper  lip,  in  the  skin  of  the  nose,  and  finally  within 
the  orbit  adjacent  to  the  lacrymal  gland.  (Vide  Plate  I,  P^ig.  8,  p.  884.) 

Macroscopic  Appearance  and  Histology. — Upon  section  mixed  tu- 
mors usually  have  a  lobulated  structure,  and  so  mottled  an  appearance 
that  they  can  scarcely  be  mistaken  for  any  other  variety  of  tumor.  Soft 
and  hard,  solid,  cystic,  and  different  colored  areas  are  intermingled. 

Microscopically  epithelial-like  cells  and  stroma,  the  relative  propor- 
tion, form,  and  arrangement  of  which  vary  in  different  tumors,  depend- 
ing upon  whether  they  are  simple  or  complicated,  are  found. 

The  epithelial-like  cells  are  cubical  and  cylindrical,  and  arranged  in 
solid  cords,  in  alveoli,  in  glandlike,  or  cystic  and  dilated  tubules.  De- 
pending upon  the  character  and  arrangement  of  the  cells,  different 
areas  may  resemble  histologically  an  adenoma  or  a  carcinoma.  AVilms 
thinks  that  the  glandular  areas  in  these  tumors  resemble  .somewhat, 
histologically,  the  anlage  of  the  parotid,  submaxillary,  and  lacrymal 
glands.  In  some  of  the  areas,  canals,  cysts,  and  alveoli  are  found  which 
are  lined  with  flat  epithelium  (including  basal  and  prickle  cells  and 
the  horny  layer  of  the  skin — Tlinsberg,  Wilms). 

The  stroma  consists  of  a  fibrillar  connective  tissue  containing  elastic 
fibers  or  a  cellular  embryonal  tissue.  Myxomatous,  cartilaginous  and 
bony  areas  are  also  found  in  the  complicated  tumors.     Different  areas 


974  DIFFERENT  VARIETIES  OF  TUMORS 

of  sneli  a  tumor  may,  tlieroforc,  resemble  a  fibroma,  a  spindle-cell  sar- 
coma, a  myxoma,  chondroma  or  osteoma,  depending  upon  the  character 
of  the  stroma. 

The  relation  between  the  parenchyma  and  stroma  of  these  tumors 
varies  a  great  deal.  These  differences  explain  the  number  of  different 
terms,  such  as  enchondronias,  enchondroma  niucosum,  and  myxomatodes, 
chondrosarcoma,  ehondroadenoma,  which  were  earlier  applied  to  these 
tumors. 

Wilms's  Theorij  as  to  Origin. — AVilms  believes  that  not  only  fully  de- 
veloped tissues,  but  also  embryonal  cells  and  tissues  in  different  stages  of 
development  are  found  in  these  tumors,  for  the  glandlike  tubules  re- 
semble closely  the  anlage  of  the  gland  in  which  they  occur.  lie  believes 
that  the  flat  epithelium  is  derived  from  the  epithelium  of  the  mouth 
cavity  or  orbit  depending  upon  the  position  of  the  tumor.  He  thinks 
that  the  mixed  tumors  of  the  salivary  glands  and  allied  tumors  occur- 
ring in  the  palate  develop  from  embryonal  rests  consisting  of  epithelium 
and  mesenchyme  which  have  remained  latent  for  a  long  time.  *  It  de- 
pends upon  the  rate  of  growth  and  the  character  of  the  different  cellu- 
lar elements  whether  a  simple  or  a  complicated  mixed  tumor  develops. 

Volkmann's  Theory  of  Metaplasia. — The  opinions  of  different  au- 
thors concerning  the  exact  nature  and  classification  of  these  tumors 
differ.  Kauff'mann,  Nasse,  Volkmann,  and  others  regard  the  mixed 
tumors  of  the  salivary  glands  as  endotheliomas.  They  believe  that  the 
stroma  may  become  converted  into  tissues  of  diff'erent  type  as  the  result 
of  metaplasia,  and  that  the  columns  of  cells  and  glandlike  tubules  are 
formed  by  the  proliferation  of  the  endothelium  lining  the  tissue  spaces 
and  lymphatic  vessels.  This  view  is  disputed  by  Hinsberg,  Wilms,  and 
Ribbert.  The  last  classifies  these  tumors  with  fibroepithelial  growths 
and  believes  that  they  develop  from  displaced  glandular  germinal  tis- 
sue, the  stroma  of  which,  because  of  its  intimate  relation  to  the  branchial 
arches,  is  capable  of  forming  bone  and  cartilage.  Hinsberg  holds  a 
somewhat  similar  view,  believing  that  the  tumors  develop  from  dis- 
placed islnnds  of  the  parotid  anlage  and  einbryonal  periosteal  tissue 
sej)Jirated  from  the  mandible. 

Mixed  Tumors  of  the  Breast. — According  to  Wilms,  tumors  of  the 
bicast,  which  have  .sometimes  been  described  as  cystosarcomas  and  adeno- 
sarcomas  with  epidermoid  cysts  (Grohe's  cystic  fibrosarcoma  with  epi- 
dermoidal  metaplasia),  sometimes  as  atheromas  or  cholesteatomas,  the 
latter  combined  with  cystosarcoma  phyllodes  (TTiickel),  should  be  clas- 
sified as  mixed  tumors. 

Clinically  they  are  most  closely  related  to  adenomas,  but  they  are 
much  less  common.  They  are  found  in  women  of  niiddle  and  advanced 
age,  occasionally  in  iikmi. 


SIMPIJ-:   MIXED   TUMORS  975 

They  appear  as  nodular,  well-defined  tumors,  which  may  he  easily 
moved  upon  the  surrounding  tissues,  and  are  covered  hy  non-adherent 
skin.  These  tumors  may  grow  rapidly  from  the  begiiining  or  after 
some  time  to  attain  considerable  size.  Finally  they  invade  the  skin 
and  the  latter  ulcerates.     jMetastases  have  not  been  observed. 

The  diagnosis  is  not  easily  made.  Depending  upon  the  rapidity  of 
growth  these  tumors  are  sometimes  regarded  as  fibromas  and  adenomas, 
at  other  times  as  sarcomas. 

Amputation  of  the  breast  is  indicated  to  prevent  recurrence. 

JMacroscopically  the  cut  surfaces  of  these  tumors  vary  in  appear- 
ance, as  sometimes  they  are  solid,  while  at  other  times  they  contain 
spaces  and  round  cysts.  Hard  and  soft  areas,  some  of  which  are  com- 
posed of  nuicoid  tissue,  are  intermingled.  Microscopically  these  tumors 
differ  a  great  deal  fi-om  the  adenomas,  eystadenomas,  and  cystosarcomas 
Avhich  they  resemble  so  closely  clinically.  Adenomatouslike  tissue  is 
found,  together  with  epidermoid  cysts  with  cheesy  contents  and  cysts 
lined  with  squamous  epithelium.  The  stroma  is  comi)osed  of  adult  and 
embryonal  connective  tissue,  containing  large  numbers  of  round  and 
spindle  cells,  loose  nnicoid  tissue,  cartilaginous  and  osteoid  masses. 
Sometimes  the  blood  vessels  have  proliferated,  and  the  tiniior  simulates 
an  angioma. 

The  origin  of  these  tumors  is  most  satisfactorily  explained  by  "Wilms, 
lie  believes  that  they  develop  from  displaced  ectodermal  tissue,  to  which 
is  also  attached  some  mesenchyme.  These  fragments  become  enclosed 
within  the  breast  tissue,  and  later  proliferate  to  form  glands,  skin,  and 
dift'erent  types  of  coiniective  tissue. 

Mixed  Tumors  of  Urogenital  System. — The  mixed  tumors  found  in 
the  urogenital  system  are  nnieh  more  malignant  than  those  occurring 
in  the  salivary  glands  and  breast. 

They  are  found  most  fre(juently  in  the  kidneys.  They  ma\'  d(>velop 
in  young  children,  and  occasionally  are  of  congenital  origin,  ])o1h  kid- 
neys being  frequently  involved.  '^I'hese  tumors  develop  most  commonly 
within  the  substance  of  the  kidney,  tlie  renal  tissue  being  displaced  and 
destroyed  by  the  new  growth.  The  tumor,  composed  of  large  nodules 
and  covered  by  the  fil)rous  capsule  of  the  kidney,  replaces  the  latter 
organ.  Frequently  only  a  small  amount  of  renal  tis.sue  remains  at 
either  pole.  The  tumor  is  either  separated  from  the  adjacent  renal 
tissue  by  a  layer  of  loose  connective  tissue,  or  is  united  to  it  by  infil- 
trating masses  and  columns  of  cells.  After  rupture  of  the  fibrous  cap- 
sule, the  tumor  invades  the  surrounding  tissue.  Polypoid  masses  may 
also  extend  from  the  tumor  into  the  pelvis  of  the  kidTiey. 

These  tumors  grow  rapidly  and  constantly,  and  become  very  large. 
Finally  they  may  fill  the  greater  part  of  the  abdominal  cavity.     They 


976  DIFFERENT   VARIETIES   OF  TUMORS 

produce  lymphogenous  and  hgematogenous  metastases,  the  latter  follow- 
ing invasion  of  the  renal  vein. 

The  prognosis  is  bad.  Even  the  results  following  extirpation  of  the 
tumor  and  the  remains  of  tlie  kidney  are  not  good,  as  these  tumors 
recur  rapidl^^  ^Metastases  and  the  weakened  condition  of  the  patient 
contribute  to  the  poor  results  of  tliese  operations. 

It  may  be  seen  upon  section  that  a  number  of  different  kinds  of 
tissue  occur  in  these  tumors.  Dense,  firm,  fibrous  areas  alternate  with 
vascular,  soft  ones  which  resemble  in  structure  a  sarcoma. 

Microscopically  one  finds  adult  and  embryonal  fibrous  tissue  with 
sarcomatous  characteristics,  mucoid  tissue,  cartilage,  and  smooth  and 
striated  muscle  fibers  in  different  stages  of  development.  Within  the 
stroma  lie  tubular  ghmds  which  remind  one  of  the  canals  of  the  primi- 
tive kidnej^  for  their  vesicular  extremities,  which  are  surrounded  by 
coiniective  tissue  and  frequently  are  invaginated,  resemble  somewhat 
glomeruli.  The  glandular  content  of  these  tumors  is  indicated  by 
the  number  of  different  names,  such  as  adenosarcoma,  adenomyxosar- 
coma,  adenomyochondrosarcoma,  etc.,  which  have  been  applied  to  them. 
Birch-Hirschfeld  was  the  first  to  group  these  tumors.  He  called  them 
"  embryonal  glandular  sarcomas." 

In  rare  cases  groups  and  masses  of  cornified,  flat  epithelium,  which 
contained  material  resembling  cholesterin,  have  been  found. 

These  mixed  tumors  must  be  the  result  of  some  developmental  dis- 
turbance occurring  during  the  formation  of  the  kidney.  According  to 
Wilms,  the  error  in  development  must  occur  very  early,  otherwise  the 
number  of  kinds  of  germinal  tissue  displaced  must  correspond  to  the 
number  found  in  the  tumor.  He  believes  that  these  tumors  develop 
from  germinal  mesoderm  separated  and  displaced  from  the  vicinity  of 
the  ])riiiiitive  kidney. 

Mixed  Tumors  of  the  Vagina.— Mixed  tumors  of  the  vagina  appear 
in  small  children  as  grapelike  growths,  which,  like  those  developing  upon 
the  cervix  of  middle-aged  people,  grow  rapidly,  fill  the  vagina,  protrude 
between  the  labia,  and  later  infiltrate  the  pelvic  connective  tissues. 
Both  forms  recur  rapidly,  ulcerate,  and  become  infected  early,  and 
cause  death  in  a  fcnv  years.     Metastases  rarely  develop. 

The  origin  of  these  tumors,  composed  of  different  forms  of  sarcoma- 
tous tissue,  together  with  muscle  fibers,  cartilage,  mucoid  tissue,  and  fat, 
may  be  most  satisfactorily  explained  by  Wilms 's  theory,  according  to 
which  they  develop  from  an  undifferentiated,  germinal,  mesodermal  tis- 
sue which  is  displaced  during  early  development. 

A  similar  histological  picture  is  presented  by  the  rare  mixed  tu- 
mors occurring  in  the  urinary  bladder,  which  appear  about  the  trigone. 
According  to  Wilms  these  also  develop  from  displaced  mesodermal  tis- 


TERATOID  TUMORS  977 

sue.  This  investigator  ascribes  tlie  same  origin  to  mixed  tumors  devel- 
oping in  the  lower  pole  of  th(!  testicle  and  along  the  vas  deferens  of 
young  children,  which,  depending  upon  the  character  of  the  tissues 
composing  them,  are  usually  called  rhabdomyomas  or  rhabdomyosar- 
comas. 

Ribbcrt  has  suggested  that  mixed  tumors  of  the  urogenital  system, 
which  are  apt  to  occur  at  definite  points,  develop  from  separated  ger- 
minal cells  which  migrate  from  the  region  of  the  kidney  through  the 
Miillerian  and  Wolffian  ducts  to  the  uterus,  vagina,  and  urinary  blad- 
der, and  perhaps  even  gain  access  to  the  vas  deferens. 

Literature. — Birch-Hirschfeld.  Sarkomatose  Driisengeschwulst  der  Niere  im 
Kindesalter  (embryonales  Adenosarkom).  Zieglers  Bcitr.  z.  path.  Anat.,  Bd.  24, 
1898,  p.  343. — Hinsbcrg.  BeitrJige  zur  Entwicklungsgeschichte  und  Natur  der  Mund- 
speichekh-iisengeschwiilste.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  51,  1S99,  p.  281. — Iliishr. 
Beitr.  z.  Lehre  von  d.  HarnbkisengeschwiUsten  iin  Kindesalter.  Jahrb.  f.  Kinderheilk., 
Bd.  62,  1905,  Part  2.—Kaujmann.  Das  Parotissarkom.  Arch.  f.  klin.  Chir.,  Bd.  26, 
1881,  p.  672. — Kiittner.  Die  Geschwiilste  der  SubmaxiUarspeicheldrlise.  Beitr.  z. 
klin.  Chir.,  Bd.  16,  1896,  p.  181. — Nasse.  Die  Geschwiilste  der  Speicheldriisen,  etc. 
Arch.  f.  klin.  Chir.,  Bd.  44,  1892,  p.  233. — Volkmann.  Ueber  endotheliale  Geschwiilste, 
zugleich  ein  Beitrag  zu  den  Speicheldriisen-  und  Gaumentumoren.  Deutsche  Zeitschr. 
f.  Chir.,  Bd.  51,  1895,  p.  1. — M.  Wilms.  Die  Mischgeschwulste,  I-III.  Berlin  und 
Leipzig,  1899,  1900,  1902. — Weitere  Literatur  siehe  bei  Borst.  Die  Lehre  von  den 
Geschwulsten.     Wiesbaden,  1902,  II,  p.  979. 


CHAPTER    II 

TERATOID    TUMORS 

(a)    COMPLICATED    DERMOID    CYSTS    OF    THE    OVARIES    AND 

TESTICLES 

(Wilms's  Cystic  Emhryomas) 

The  most  striking  characteristic  of  these  growtlis,  which  are  usually 
benign,  is  their  similarity  to  simple  dermoid  cysts,  which  consist  only 
of  follicles  of  skin  provided  with  hair  and  glands  and  have  cheesy  con- 
tents. The  presence,  however,  of  large  amounts  of  hair,  of  teeth,  and 
particles  of  bone  indicates  the  complicated  structure  of  these  tumors, 
and  for  this  reason  they  are  differentiated  from  the  simple  dermoid 
cysts. 

Common  Occurrence  in  Ovaries. — They  are  found  most  frequently  in 
the  ovary,  forming  nine  per  cent  of  all  ovarian  tumors.  These  tumors 
are  found  more  rarely  in  children  than  in  adults,  but  apparently  all  of 
them  are  the  result  of  anomalies  in  development.  They  develop  as  single 
or  multiple  growths  in  one  or  both  ovaries,  and  may  be  situated  within 


978  DIFFERENT   VARIETIES  OF   TUMORS 

the  latter  organs  as  well  as  upon  their  surfaces.  When  situated  upon 
the  surface  of  the  ovaries  they  are  frequently  pedunculated.  When  the 
pedicle  is  broken,  they  lie  free  in  the  lower,  occasionally  in  the  upper 
abdomen  (e.  g.,  in  the  lesser  peritoneal  cavity).  The  cysts  which  lie  at 
a  distance  from  the  ovaries  may  have  developed  from  accessory  ovaries. 

These  cysts 'usually  grow  slowly,  but  may  become  as  large  as  a  man's 
head.  Then  the  ovary  is  partially  or  completely  destroyed.  Occasion- 
ally the  cyst  wall  ruptures,  and  then  viable  germinal  tissue  from  which 
other  small  cysts  develop  is  transplanted  upon  the  peritoneum.  Carci- 
nomas, usually  of  the  squamous-cell  variety,  may  develop  from  the  walls 
of  these  cysts. 

Symptoms — Torsion  of  Pedicle,  etc. — The  first  symptoms  are  usually 
produced  by  pressure  upon  neighboring  organs  after  the  cysts  attain 
considerable  size,  or  by  secondary  disturbances  which  may  be  followed 
by  serious  consequences.  Pedunculated  cysts  are  frequently  deprived 
of  nutrition  by  torsion  of  their  pedicles.  When  torsion  occurs  the  cyst 
becomes  necrotic,  contracts  adhesions  with  neighboring  structures,  or 
may  rupture  in  the  bladder  or  intestines. 

Frequently  cysts  after  torsion  of  the  pedicle  are  invaded  by  intes- 
tinal bacteria,  and  then  suppurate  or  undergo  putrefactive  changes. 
A  progressive  fatal  peritonitis  may  follow  infection  of  one  of  these  cysts. 

It  is  difficult  to  make  a  difi'erential  diagnosis  between  dermoid  cysts 
and  other  tumors  which  occur  in  the  ovary  and  tissues  adjacent  to  it. 

Treatment. — The  treatment  consists  of  complete  removal,  together 
with  the  remnants  of  the  ovary  involved. 

Complicated  Dermoids  of  the  Testicles. — The  complicated  dermoid 
cysts  of  the  testicle  are  much  rarer.  They  are  more  rare  in  adults  than 
in  small  children,  in  whom  they  are  frequently  congenital.  Occasion- 
ally they  develop  in  undescended  testicles.  They  occur  as  single  growths 
and  are  found  only  within  the  testicles,  not  occurring  upon  the  surface, 
and  usually  develop  from  the  substance  of  the  organ,  only  small  rem- 
nants of  the  latter  remaining  upon  the  surface  of  the  tumor.  Tumors 
situated  without  the  testicle — for  example,  in  the  scrotum — are  rare. 

They  grow  slowly,  the  patient's  attention  usually  first  being  attracted 
to  the  growth  by  its  size,  and  never  give  rise  to  the  severe  symptoms 
which  are  sometimes  associated  with  similar  growths  of  the  ovaries. 
They  may  be  dififerentiated  from  other  slowly  growing  tumors  of  the 
testicles  by  their  doughy  consistency. 

Castration  is  indicatod  in  the  treatment  of  these  tumors. 

Macroscopic  Appearance  and  Histology. — According  to  the  investiga- 
tions of  Wilms,  the  complicated  dei'moid  cysts  of  the  testicles  and  ovary 
are  peculiar  in  that  they  contain  a  nidimetitary  eiiibVyonal  anlage,  and 
therefore  he  has  called  these  growths  cyslic  cmhryo^HUS. 


TERATOID  TUMORS  979 

Tlio  inner  surface  of  tlie  firm  cyst  wall,  wliich  is  not  of  the  same 
tliiekness  tliroughont,  contains  a  nunil)er  of  tumorlike  projections.  Some- 
times these  projections  resemble  villi,  sometimes  nodular  thickenings, 
while  at  other  times  they  appear  as  septa  between  cavities  within  the 
cyst.  These  projections  are  covered  with  skin,  Avhieh  is  fre([uently  cov- 
ered with  masses  of  hair,  and  often  contain  teeth  connected  with  pieces 
of  bone  which  extend  into  the  deeper  parts  of  the  cyst  wall.  Cysts  of  this 
character  contain  derivatives  of  the  three  germinal  layers.  These  deriva- 
tives resemble  the  structures  of  the  cephalic  portion  of  an  embryo,  but 
do  not  have  the  irregular  arrangement  found  in  teratoid  mixed  tumors 
(Wilms).  Subcutaneous  fat,  cartilage,  bone,  muscle  fibers,  and  even 
brain  tissue  with  corpora  amylacea  may  be  found  beneath  the  skin 
lining  such  a  cyst.  In  some  parts  of  the  cysts  the  skin  becomes  continu- 
ous with  mucous  membrane  covered  with  squamous  epithelium,  and  the 
latter  with  cylindrical  or  ciliated  epithelium  lining  a  canal,  the  char- 
acter and  arrangement  of  the  epithelium  being  similar  to  that  found 
in  the  mouth  cavity  of  the  embryo.  Some  of  the  cysts,  the  walls  of 
Avhich  contain  rings  of  cartilage  and  smooth  muscle  fibers,  resemble  in 
structure  the  respiratory  passages,  while  others,  lined  with  goblet  cells 
and  filled  with  mucus,  the  walls  of  which  contain  smooth  muscle  fibers, 
resemble  histologically  the  intestines.  Widely  different  types  of  tissues 
may  be  found  which  have  often  been  regarded  as  rudiments  of  an  eye, 
of  the  thyroid  gland,  trachea,  mammary  gland,  etc.  The  greater  part 
of  the  walls  of  these  cysts  is  lined  with  skin,  the  remaining  part  is  lined 
with  cylindrical  epithelium  or  covered  with  granulation  tissue. 

Naturally  the  different  tissues  do  not  reach  the  same  degree  of  de- 
velopment in  the  different  tumors.  The  embryonal  tissues  and  organs 
which  develop  earliest  predominate,  viz.,  the  ectoderm  and  the  tissues 
and  organs  of  the  cephalic  region.  The  development  of  the  other  tis- 
sues is  prevented  by  the  rapid  growth  of  those  which  differentiate  early 
(Wilms). 

Theories  as  to  Origin. — Different  theories  have  been  advanced  to  ex- 
plain the  development  of  these  complicated  dermoid  cysts  (embryomas) 
in  the  testicles  and  ovaries.  It  has  been  suggested  that  they  are  the 
result  of  abnormal  proliferative  changes  in  the  spermatozoa  or  ova, 
which  occur  without  fertilization,  the  process  having  been  called  par- 
thenogenesis. 

The  possibility  of  the  parthenogenetic  origin  of  cysts  of  this  character 
has  been  disputed  by  Bonnet.  He  believes  that  these  tumors  develop 
from  blastomeres  which  have  not  gone  on  to  full  differentiati(]n  or  from 
fertilized  polar  globules.  Marchand  and  Wilms  believe  that  the  tumors 
occurring  in  the  testicle  and  ovary  may  develop  from  excessive,  unused 
blastomeres.     They  do  not  accept  Bonnet's  view  that  they  may  develop 


980  DIFFERENT   VARIETIES  OF   TUMORS 

from  polar  globules,  as  cases  have  been  observed  in  wliicli  five  embry- 
omas  have  been  found  in  an  ovary,  while  in  the  normal  human  ovum 
usually  only  two,  never  more  than  three,  polar  globules  are  formed 
(Wilms). 

According  to  Wilms  these  tumors  develop  from  germinal  tissue  con- 
taining the  three  layers  which  is  displaced  during  development.  This 
theory  explains  most  satisfactorily  not  only  the  development  of  the  com- 
plicated dermoid  cysts  found  in  the  ovaries  and  testicles,  but  also  that  of 
the  teratoid  mixed  tumors  occurring  in  these  organs.  Teratoid  tumors 
and  teratomas  are  supposed  by  some  to  develop  from  unused,  displaced 
blastomeres,  by  others  from  fertilized  polar  globules.  The  genetic  rela- 
tionship between  these  tumors  and  dermoids  of  the  ovary  is  demon- 
strated by  the  occurrence  within  the  abdominal  cavity  of  tumors,  which 
are  morphologically  similar  to  dermoids  of  the  ovary,  but  have  no  con- 
nection with  the  latter  organ.  It  has  not  been  satisfactorily  explained 
why  the  displaced  germinal  tissue  produces  such  different  macroscopic 
and  microscopic  pictures  when  it  proliferates. 


(b)  TERATOID   MIXED  TUMORS 

(Emhrymd  Tumors,  Wilms) 

The  tumors  placed  in  this  group  differ  from  the  complicated  der- 
moid cysts  in  that  they  are  solid  or  polyc.ystic ;  from  teratomas  in  the 
absence  of  any  higiily  developed  rudiments.  They  are  formed  as  a 
result  of  the  irregular  proliferation  of  derivatives  of  the  three  germinal 
layers  (therefore,  tridermoma,  Wilms).  They  have  a  miTch  more  varied 
structure  than  the  simple  mixed  tumors. 

These  tumors  may  develop  in  any  part  of  the  body  in  which  tera- 
tomas occui',  but  are  found  most  frecjuently  in  the  testicles  and  ovaries. 

Teratoid  Mixed  Tumors  of  Testicles. — Teratoid  mixed  tumors  of  the 
testicles  develop  most  commonly  between  the  twentieth  and  fortieth 
years  of  life.  They  grow  slowly  to  form  large  nodular  tumors  of 
irregular  size  and  varying  consistency.  The  changes  produced  in  the 
surrounding  tissues  by  these  tumors  are  very  similar  to  those  produced 
by  complicated  dermoids.  They  become  malignant  with  relative  fre- 
quency. These  tumors  may  assume  a  sarcomatous,  more  rarely  an 
adenocarcinomatous  structure,  and  may  rupture  through  the  capsule 
formed  by  the  tunica  albuginea,  may  infiltrate  the  suri-ounding  tissues 
and  form  numerous  metastases,  which  often  correspond  histologically  to 
the  malignant  part  of  the  tumor  only.  Frequently,  however,  the  metas- 
tases contain  the  derivatives  of  the  three  germiual  layei's.  Death  soon 
follows  tlie  formation  of  metastases. 


TERATOID  TUMORS  981 

The  varying  consistency  of  the  slowly  growing:  timiors  is  the  most 
important  diagnostic  point.  When  these  tumors  assume  malignant  char- 
acteristics they  cannot  be  differentiated  from  sarcomas  and  carcinomas 
of  the  testicle. 

Macroscopical  Appearance  and  Histology. — Depending  upon  the  char- 
acter of  the  tissue  which  predominates,  these  tumors  have  been  called 
chondromas,  cystosarcomas,  chondroadenomas,  adenocystomas,  adenomyo- 
sarcomas,  cystocarcinomas,  etc.,  of  the  testicle.  Wilms  has  shown  that 
almost  all  of  these  tumors  contain  derivatives  of  the  three  gerininal 
layers,  but  when  the  derivatives  of  the  entoderm  and  mesoderm  pre- 
dominate those  of  the  ectoderm  may  be  w^anting.  The  different  tissues 
found  in  these  tumors  have  a  very  irregular  arrangement  and  structure. 
The  stroma  may  contain  embryonal  and  adult  forms  of  fibrous  tissues, 
myxomatous  tissue  and  fat,  cai'tilage  and  bone,  smooth  and  striated  nnis- 
cle  fibers,  and  renniants  of  the  peripheral  and  central  nervous  system. 
Scattered  throughout  the  stroma  may  be  found  glandular  structures 
varying  in  form  and  arrangement,  spaces  and  cysts  lined  with  different 
forms  of  epithelium,  the  contents  of  which  differ.  Frequently  the 
mucous  membrane  found  in  these  tumors  resembles,  histologically,  that 
of  the  mouth  and  pharynx  or  intestinal  tract. 

Teratoid  Mixed  Tumors  of  the  Ovary. — Teratoid  mixed  tumors  of 
the  ovary,  like  complicated  dermoid  cysts,  develop  within  the  organ, 
upon  its  surface,  or  in  the  surrounding  tissues.  They  develop  most 
frequently  during  puberty,  and  grow  slowly,  unless  they  undergo  ma- 
lignant changes. 

Upon  section  these  tumors  have  a  mottled  appearance,  and  deriva- 
tives of  the  three  germinal  layers  may  be  found.  Occasionally  these 
derivatives,  especially  those  of  a  cephalic  region,  are  fairly  well  devel- 
oped, being  similar  to  the  structures  already  described  in  complicated 
dermoid  cysts. 

Occurrence  in  Other  Organs. — Teratoid  mixed  tumors  occur  in  the 
buccal,  nasal,  and  pharyngeal  cavities  as  hairy  polyps  (Arnold).  They 
are  also  found  within  the  skull,  being  situated  within  tlie  venti-icles  or 
at  the  base  of  the  brain,  appearing  as  tumors  of  the  hypophysis.  They 
may  be  found  within  the  chest  (wdthin  the  mediastinum  or  peri- 
cardium) and  in  the  abdominal  cavity  (in  the  transverse  mesocolon, 
the  lesser  peritoneal  cavity,  in  the  mesentery  or  retroperitoneal  tissues 
upon  the  left  side,  close  to  the  spinal  column).  Tumors  occurring  in 
the  abdomen  develop  from  parts  of  fcrtal  abdominal  organs  displaced 
during  the  rotation  of  the  intestines  and  the  changes  occurring  in  the 
foetal  peritoneum,  which  terminate  in  its  fusion  with  the  posterior 
abdominal  wall.  Tumors  of  this  class  are  also  found  in  front  of  and 
behind  the  coccyx  and  sacrum ;  in  short,  wherever  teratomas  occur.     It 


982  DIFFERENT    VARI1:TI1<]S   OF   TUMORS 

should  be  mentioned  that  B.  Fischer  has  found  one  of  these  tumors  in 
the  muscles  of  the  calf  of  a  male  patient. 

Removal  by  operation,  which  may  be  very  difficult,   is  always  in- 
dicated. 


CHAPTER    III 

TERATOMAS 

The  tumors  of  this  group,  which  are  rare,  form  a  transition  between 
the  teratoid  mixed  tumors  and  the  double  malformations,  such  as  a 
foetus  in  foetu.  They  are  therefore  on  the  border  line  between  new 
growths  and  malformations.  Some  of  the  double  malformations  may 
assume  tumorlike  growths. 

Teratomas  are  always  congenital,  that  is,  the  tumor  is  present  at  the 
time  of  birth  or  the  patient  is  born  with  the  essential  tumor  matrix. 

Position. — These  tumors  either  lie  near  the  surface  of  the  body — for 
example,  teratomas  of  the  mouth  which  are  attached  to  the  base  of  the 
skull,  teratomas  of  the  neck  and  coccygeal  region — or  within  the  body 
cavities   (pleura  and  peritoneum). 

Size  and  Form. — Teratomas  may  be  of  considerable  size  at  birth,  or 
if  the  child  survives  may  gradually  become  of  considerable  size  dur- 
ing subsecpient  growth. 

Shape  and  Consistency. — These  tumors  vary  in  shape,  their  surfaces 
usually  being  nodular  and  irregular.  As  they  are  composed  of  cystic 
and  solid  areas,  the  consistency  of  various  tumors  differs.  Frequently 
a  dense  connective-tissue  capsule  surrounds  such  a  tumor,  separating  it 
from  the  surrounding  tissues.  Large  vessels  enter  the  capsule,  usually 
at  the  point  Mt  which  the  tumor  first  commenced  to  develop.  A  tera- 
toma of  the  abdominal  cavity  may  have  an  amnionlike  membrane  sur- 
rounding it  (Fig.  444).  When  one  of  these  tumors  develops  near  the 
surface  of  the  body  the  skill  may  form  a  capsule. 

Differences  Between  Teratomas  and  Teratoid  Mixed  Tumors. — Tera- 
tomas differ  from  teratoid  mixed  tumors  in  containing  highly  developed 
fo'tal  structures.  It  is  not  always  jiossible,  however,  to  make  a  sharp 
distinction  between  these  two  classes  of  tumors.  Teratomas  contain 
incompletely  developed  ])ai-ts  of  llie  skeleton,  such  as  the  skull,  man- 
dible, bones  of  the  extremities,  eiilire  exti'emities  or  parts  of  the  same 
with  joints,  finticrs,  or  toes  in  dilTerent  stages  of  develoi)ment ;  intes- 
tinal loops  willi  a  mesentei-y ;  cysts  i'eseiiil)liiig,  Iiistologieally,  stomach, 
Iving,  thyroid,  ki(hiey,  and  panci-eas  lissne;  pieces  of  the  brain  with 
convolutions  and   ventricles;   anlage  of  the  bronchi,  eyes,  nerves,   etc 


TERATOMAS 


983 


The  parts  covered  with  skin  project  into  a  dernioidlikc  cavity  or  are 
surrounded  by  amnion.  These  different  kinds  of  tissue  are  held  to- 
gether by  tumorlike  masses  which  correspond  to  the  different  germinal 
layers  from  which  they  develop. 

One  gains  the  imi)ression,  when  such  a  tumor  is  examined,  that  the 
growth  of  the  cells  of  one  of  the  germinal  layers  has  been  suppressed 
or  that  the  cells  have  been   partially   destroyed,   and  that  the   layers 


Fig.  444. — A  Teratoma  the  Size  of  a  Fist  Removed  from  a  Girl  Baby  Seven  Weeks  Old 
BY  Operation.  The  tumor  lay  in  the  foramen  of  Winslow,  just  beneath  the  Hver  and 
was  adherent  to  the  hepato-duodcnal  ligament,  from  which  its  nutrient  vessels  were 
derived.  (Lexer.)  1,  The  pedvmeulated  sac  of  skin  contains  an  anlage  of  the  head, 
consisting  of  brain  cavities,  connective-tissue  skull,  well-develojied  scalp,  and  anlage  of 
teeth  which  extend  into  the  pedicle  and  squamous  cell  epithelium,  which  resembles 
that  of  the  mouth.  2,  Capsule  of  the  tumor  open.  2a,  Point  of  attachment  of  tumor. 
The  tumor  also  contains  a  cyst  situated  close  to  the  anlage  of  the  head  which  is  provided 
with  ciliated  epithelium  and  goblet  cells,  mucous  glands,  smooth  muscle  fibers  and 
hyaline  cartilage  (anlage  of  the  respiratory  passages).  The  principal  part  of  the  nodular 
tumor  is  a  teratoid  (polycystic)  mixed  tumor.  Hi,  Hi,  Nodules  of  skin  attached  to 
the  head  anlage. 


984  DIFFERENT   VARIETIES   OF   TUMORS 

which  possessed  sufficient  growth  energy  have  proliferated  to  form  im- 
perfect organs,  which,  however,  have  no  definite  morphological  or  func- 
tional relations  with  each  other. 

Diagnosis. — The  correct  anatomical  diagnosis  depends  upon  the  posi- 
tion of  the  tumor.  The  nature  of  a  superficial  tumor  occurring  in  areas 
in  which  tumors  of  this  character  are  common  is  recognized  earlier  than 
that  of  a  similar  tumor  situated  in  the  pleural  or  peritoneal  cavities. 
Of  course  tumors  of  the  pleural  cavities  are  inaccessible.  If  extremities 
or  teeth  can  be  demonstrated  in  tumors  of  the  abdomen  by  palpation 
or  by  Rontgen-ray  examination,  a  diagnosis  can  be  made  with  some 
degree  of  certainty.  In  some  of  the  cases,  however,  the  parts  are  so 
rudimentary  that  it  is  difficult  to  interpret  the  findings. 

Teratomas  have  frequently  been  removed  by  operative  procedures, 
but  only  a  few  of  the  cases  have  been  successful. 

Origin  of  Teratomas. — A  teratoma  never  springs  from  a  postnatal 
matrix.  Many  of  the  tumors  occurring  about  the  cephalic  and  caudal 
extremities  develop  from  germinal  tissue  which  has  been  displaced  dur- 
ing fusion  of  the  germinal  plates,  and  from  embryonal  structures  which 
normally  undergo  involution,  such  as  the  neurenteric  canal,  the  po.st- 
anal  gut,  the  medullary  tube,  and  the  caudal  vertebras. 

Monogerminal  and  Bigerminal  Tumors. — Tumors  developing  from  dis- 
placed rests  or  from  structures  which  normally  undergo  involution  are 
called  monogerminal  tumors,  while  those  which  resemble  fcetal  inclu- 
sions are  called  higerminal  tumors  (bigerminal  teratomas  or  foetal  in- 
clusions, parasitic  implantations,  parasites,  foetus  in  foeiu). 

It  is  not  always  easy  to  differentiate  between  these  two  groups.  The 
differentiation  is  usually  based  upon  the  following  principle :  If  the 
tissues  or  organs  found  in  the  tumor  resemble  those  normally  found  in 
the  area  where  the  tumor  is  situated,  the  latter  is  regarded  as  a  mono- 
germinal tumor,  while  if  the  tissue  found  in  the  tumor  is  foreign  to 
the  area  in  which  th(^  former  occurs  it  is  called  a  bigerminal  tumor. 

LiTRRATURi;. — Arnold.  Behaarte  Polypen  tier  Rachen-Mundhohle.  Virchows 
Archiv,  Bd.  Ill,  1888,  p.  ll&.—Aschoff.  Zysten.  Ergebn.  d.  allg.  Path.,  II,  1897,  p. 
4.')0. — Borst.  Die  angeborenen  Geschwiilste  der  Sakralregion.  Zentralbl.  f.  alJg. 
Patli.,  Bd.  9,  1898,  j).  459. — Engelmann.  Beitrage  zur  Kenntnis  der  Sakraltumoren. 
Arch.  f.  klin.  Cliir.,  Bd.  72,  1904,  p.  942. — B.  Fischer.  Ueber  ein  Embryom  der  Wade. 
Miinch.  med.  Wochoiischr.,  190.'5,  p.  1.569. — Kirmisson.  Chirurgische  Krankheiten 
angohf)rnnen  Ur.sprunges.  Stuttgart,  Enke,  1899. — Kleinwachtcr.  Ueber  operierte 
Krcuzhciinparasiten,  etc.  Zeitschr.  f.  Heilkunde,  Bd.  9,  p.  1. — Lexer.  Ueber  teratoide 
Geschwiilste  in  der  Bauchhohle  und  deren  Operation.  Arch.  f.  klin.  Chir.,  Bd.  61,  1900, 
p.  648; — Operation  einer  fcitalen  Inklusion  in  der  Bauchhohle.  Arch.  f.  klin.  Chir., 
Bd.  62,  1900,  p.  3.51. — Linser.  Ueber  Sakraltumoren  und  eine  seltene  fcitale  Inklusion. 
Bcitr.  z.  klin.  Chir.,  Bd.  29,  1901,  p.  .'^88. — Marchand.  Sakraltumoren.  Eulcnhurgs 
KcMlenzyklopildie,  Bd.  2.5,  1899. — Achilles  Midler.     Zur  Kenntnis  der  Hodcnembryome, 


I 


TERATOMAS  985 

Arch.  f.  klin.  Chir.,  Bd.  76,  1905,  p.  001. — Masse.  Reitragc  zur  Genese  der  sacrococcy- 
gealen  Teratome.  Arch.  f.  klin.  Chir.,  Bd.  45,  189.'i,  p.  985. — Olto.  Ueber  einen  konge- 
nitalen  behaarten  Rachenpolypen.  Virchows  Archiv,  Bd.  115,  1889,  p.  242. — Pupovac. 
Ein  Fall  von  Teratoma  colli  mit  Veranderungen  in  den  regionaren  Lyinphdriisen. 
Arch.  f.  klin.  Chir.,  Bd.  53,  1890,  p.  59. — Saxcr.  Ein  zum  grossten  Teil  aus  Derivaten 
der  Medullarplatte  best ehendes  grosses  Teratom  im  3.  Ventrikel  eines  Twochentlichcn 
Kindes.  Zieglers  Beitr.  z.  path.  Anat.,  Bd.  20,  1896,  p.  3\)9.~Wetzel.  Zur  Kasuistik 
der  Teratome  des  Halses.  I.-D.,  Giessen,  1895. — Wilms.  Dermoidzysten  und  Tera- 
tome. Deutsch.  Arch.  f.  klin.  Med.,  Bd.  55,  1895,  p.  289; — Ueber  die  soliden  Teratome 
des  Ovarium.  Zieglers  Beitr.  z.  path,  Anat.,  Bd.  19,  1895,  p.  307; — Die  teratoiden 
Geschwiilste  des  Hodens.  Ibid.,  Bd.  19,  1896,  p.  233; — Embryome  und  embryoide 
Tumoren  des  Hodens.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  49,  1898,  p.  1; — Multiple  Em- 
bryome des  Ovarium.  Monatsschr.  f.  Geburtsh.,  Bd.  9,  1899,  p.  585. — Weitere  Ijiteratur 
siehe  bei  Borst.     Die  Lehre  von  den  Geschwiilsten.     Wiesbaden,  1902,  II,  jip.  980-982. 


63 


PART   VII 

CYSTS,  :not  i:t^cLUDiisrG  cystic  tumors 

Definition — Unilocular  and  Multilocular  Cysts. — A  cyst  is  a  circum- 
scribed cavity,  the  contents  of  which  may  be  thin,  thick,  or  atheromatous, 
separated  from  tlie  surrounding  tissues  by  a  connective-tissue  membrane 
or  by  tissue  of  complex  structure.  Cysts  with  but  a  single  cavity  are 
called  unilocular,  while  cysts  with  many  cavities  are  called  multilocular. 
Cysts,  as  they  develop,  tend  to  become  spherical,  but  the  form  is  modi- 
fied by  the  resistance  offered  by  surrounding  structures,  such  as  fascia 
and  bone,  by  adhesions  which  the  wall  of  the  cyst  contracts,  and  by 
the  form  of  the  original  cavity. 

There  are  a  number  of  varieties  of  cysts  which  have  no  relation 
whatever  to  true  tumors,  besides  the  cysts  which  develop  as  the  result 
of  peculiarities  of  growth  in  true  tumors  (embryonal  cysts,  cystade- 
nomas)  and  as  the  result  of  softening  and  liquefaction  in  solid  tumors. 

Four  varieties  of  cysts,  which  include  the  false  as  well  as  the  true, 
may  be  differentiated.  A  true  cyst  has  either  an  epithelial  or  endo- 
thelial lining,  while  the  connective-tissue  capsule  of  the  false  cyst  has 
no  lining  at  all. 

(1)  VIRCHOWS   EXUDATION    OR    EXTRAVASATION    CYSTS 

Cysts  of  this  character  are  formed  when  an  exudate  or  blood  is 
poured  out  into  a  preexisting  cavity,  or  one  formed  as  the  result  of 
some  pathological  process.  A  hydrocele  of  the  tunica  vaginalis  testis 
or  of  the  spermatic  cord  is  the  best  exnmple  of  nn  exudatiim  cyst.  The 
serous  exudate  formed  during  a  chronic  inHammation  fills  the  remains  of 
the  processus  vaginalis  peritonei.  In  hygromas — cysts  of  the  bursa^  and 
tendon  shcjiths — the  serous  or  seroha'mon'hagic  exudate  formed  during 
the  chronic  infiannnation  is  likewise  poured  out  into  a  preexisting  cavity. 
An  ascites,  a  hydr()i)s  of  n  joint,  or  a  hydrocephnlus  might  be  spoken  of 
as  a  cyst,  but  the  anjitomicjil  relations,  which  are  not  the  same  as  in  cysts, 
do  not  permit  of  it.  On  the  other  hand,  an  empty  hernial  sac  or  a  menin- 
gocele may  be  shut  off  from  the  cavity  \w\\\\  which  it  formerly  connnuni- 
cated  ;  the  fluid  secreted  by  the  endotheliMl  lining  can  then  no  Icmger  es- 
ca{)e,  add  the  liernial  and  niein'ngeal  sac  becomes  ti'ansfoi'ined  in  a  cyst. 
986 


CYSTS,    .NOT    LNCLUDl.NG   CYSTIC    TIMORS  987 

Haematocele. — A  ha-matocele  follows  the  exudation  of  blood  into  the 
tunica  vaginalis  testis.  The  contents  of  a  haematocele  consist  partly  of 
fluid,  partly  of  friable,  coagulated  blood.  The  tunica  vaginalis  becomes 
thickened  by  deposits  of  fibrin  and  as  the  result  of  connective-tissue 
proliferation.  If  blood  is  poured  out  between  the  ends  of  a  muscle 
which  has  been  lacerated  or  contused  without  separation  of  the  over- 
lying skin,  a  traumatic  blood  cyst  is  formed.  The  blood  and  necrotic 
tissue,  which  later  becomes  liquefied,  are  surrounded  by  a  connective- 
tissue  capsule,  the  result  of  a  reactive  inflammation. 

Pneumatocele. — The  rare  circumscribed  collections  of  air  between  the 
bones  of  the  skull  and  the  overlying  periosteum,  which  are  known  as 
pneumatoceles,  may  also  be  classified  with  this  variety  of  cysts.  They 
occur  on  the  forehead  and  in  the  occipital  region  just  behind  the  ear, 
and  communicate  with  the  frontal  sinus  and  the  air  cells  of  the  mastoid, 
respectively,  by  small  holes  in  the  bones.  The  clear  tympanitic  note, 
the  increase  in  the  size  of  the  swelling  during  expiration  when  the  nose 
and  mouth  are  closed,  the  decrease  in  size  of  the  swelling  when  pressure 
is  made,  and  the  position  of  the  swelling  are  the  most  important  char- 
acteristics. A  pneumatocele  may  be  cured  by  simple  incision,  as  the 
granulation  tissue  which  forms  following  the  use  of  a  tampon  may  close 
the  opening  in  the  bone.  If  the  swelling  returns,  an  osteoplastic  opera- 
tion may  be  required  (von  Bergmann). 


(2)  LIQUEFACTION   CYSTS 

The  second  variety  of  cysts  comprises  those  which  result  from  the 
softening  and  liquefaction  of  tissue.  Softening  and  liquefaction  follow 
nutritional  changes  in  the  tissues.  The  thin  or  colloidlike  masses  pro- 
duced by  the  softening  and  liquefaction  of  the  dead  tissue  are  sur- 
rounded by  a  connective-tissue  capsule  which  varies  in  thickness  and 
degree  of  development  in  different  cases.  Liquefaction  cysts  frequently 
develop  in  tumors. 

Cysts  developing  in  the  brain  secondary  to  ischa^mic  softening  and 
the  colloid  cysts  of  capsular  ligaments  and  joints,  known  as  ganglia, 
which  are  closely  related  to  hygromas  developing  in  bursne,  belong  to 
this  class.  Abscesses,  the  contents  of  which  consist  partly  of  liquefied 
necrotic  tissue  and  partly  of  inflammatory  exudate,  are  closely  related 
to  this  variety  of  cysts. 

(3)  RETENTION   CYSTS 

If  the  duct  or  canal  of  a  gland  or  cavity  which  secretes  or  contains 
a  fluid  becomes  closed  and  the  secretion  or  fluid  continues  to  form,  the 


988  CYSTS,   NOT   INCLUDING  CYSTIC  TUMORS 

gland  or  cavity  becomes  dilated  to  form  a  cyst  (Virchow's  dilatation 
and  retention  cysts).  The  tissues  composing  the  wall  of  the  gland  or 
cavity  proliferate  as  the  result  of  the  irritation  produced  by  the  accu- 
mulation of  fluid,  and  the  cyst  enlarges  until  further  growth  is  pre- 
vented by  physiological  or  anatomical  conditions. 

Cysts  of  this  variety  are  found  in  cavities,  glands,  and  blood  vessels. 

(a)  Hydrops  Vesicae  Felleae,  Pyosalpinx,  etc. — Hydrops  of  the  gall- 
bladder is  the  best  and  most  common  example  of  cystic  changes  in  a  hol- 
low organ  following  the  occlusion  of  its  duct.  If  the  lumen  of  the  cystic 
duct  is  closed  by  a  gallstone  or  occluded  by  cicatricial  contraction  of 
its  walls,  the  walls  of  the  gall-bladder  become  distended  by  the  mucus 
which  collects  and  the  gall-bladder  becomes  transformed  into  a  structure 
resembling  in  form  a  cucumber  (hydrops  vesicae  fellege,  Fig.  445).  Simi- 
lar changes  may  occur  in  the  vermiform  appendix  following  cicatricial 
stenosis  of  its  lumen.  The  appendix  then  becomes  transformed  into  a 
cyst,  resembling  a  pear  in  shape,  which  is  filled  with  masses  of  mucus 
(hydrops  processus  vermiformis).  These  changes  occur  frequently  in 
the  Fallopian  tubes  following  obliteration  of  both  the  abdominal  and 
the  uterine  ends.    The  cysts  thus  formed  are  called,  depending  upon  the 


V 


Fig.  445. — Hyuuops  of  the  Gall-bladder.      (One  half  natural  size.)     A  gallstone  may  be 
seen  showing  through  the  beginning  of  the  cystic  duct. 

character  of  their  contents,  hydrops  tubarum,  pyosalpinx,  and  hai'raato- 
salpinx.  Hydronephrosis  is  another  example.  In  hydronephrosis  the 
escape  of  urine  is  permanently  or  intermittently,  completely  or  partially 
prevented  by  some  congenital  anomaly,  torsion,  or  cicatricial  stenosis  of 
the  ureter  or  by  the  incarceration  of  a  stone.  The  urine  gradually  col- 
lects in  the  pelvis  of  the  kidney,  resulting  in  a  marked  dilatation  of  the 
latter,  and  a  gradual  destruction  of  the  parenchyma  of  the  kidney 
occurs,  so  that  in  advanced  cas(\s  only  a  few  reiiniants  of  kidney  tissue 
rciiKiiii. 

(b)   Retention  cysts  of  glands  develop  either  in  the  ducts  or  in  the 
bodies  of  the  glands. 


CYSTS,   NOT   INCLUDING  CYSTIC  TUMORS 


989 


Fig.   446. 


Atherom-a.  of  the 
Ear. 


1.  Sebaceous  Cyst  or  Atlicrotna. — An  atheroma  is  a  retention  cyst 
of  a  sebaceous  glaucl,  the  cyst  developing  either  in  the  duct  or  body  of 
the  gland.  A  comedo,  which  appears  as  a  black  point  in  the  skin,  and 
may  be  expressed  together  with  a  wormlike  mass  of  secretion,  indicates 
the  beginning  of  retention  which  may  eventually  end  in  cyst  formation. 

3Iode  of  Formation,  Lining  and  Contents  of  Cysts. — The  excretory 
duct  of  the  sebaceous  gland  may  be  blocked  as  the  result  of  the  forma- 
tion of  the  crusts,  of  uncleanliness,  or  of  in- 
flammation. If  the  accumulation  of  secre- 
tion is  limited  to  the  excretory  duct,  a  small 
cyst  filled  with  fatty  contents,  which  never 
becomes  larger  than  a  hemp  seed,  forms. 
According  to  Chiari,  if  the  body  of  the  gland 
is  involved  the  orifice  of  the  duct  dilates 
first,  the  body  of  the  gland  later.  A  cyst 
then  develops  which  lies  in  the  corium  and 
is  attached  to  the  npper  layers  of  the  skin 
by  the  outer  occluded  parts  of  the  duct  of 
the  gland.  The  cyst  may,  however,  gradu- 
ally enlarge  and  finally  extend  into  the 
subcutaneous  tissues.  The  cyst  wall,  which 
is  but  loosely  attached  to  the  surrounding 

tissues,  consists  of  a  thin  layer  of  fibrous  connective  tissue,  while  its 
inner  surface  is  lined  by  a  number  of  layers  of  flattened  epithelial 
cells  with  the  stratum  Malpighii,  but  containing  no  papilla?.  Eem- 
nants  of  the  sebaceous  gland  and  hair  follicles  may  also  be  found  in 
the  wall  of  the  cyst.  These  cysts  contain  a  yellowish  white  or  gray- 
ish, fatty,  salvelike  mass,  which  has  been  compared  to  cooked  barley. 
Frequently  the  mass  is  foul-smelling  and  mixed  with  pus.  The  eai'lier 
the  renniants  of  the  sebaceous  gland  disappear  from  the  cyst  the  more 
cornified  the  contents  of  the  cyst,  which  may  be  recognized  by  the  dry 
characteristics  and  the  stratification. 

The  smallest  atheromas,  which  appear  as  round,  hard,  white  nodules 
in  the  skin,  may  be  easily  recognized.  These  may  gradually  enlarge  to 
become  as  large  as  a  cherry  or  walnut,  occasionally  as  large  as  a  fist, 
and  are  covered  by  and  attached  to  tense,  white  or,  because  of  stasis  in 
the  small  veins,  bluish  discolored  skin. 

Regressive  Changes. — Calcification  of  the  cyst  wall,  suppurative  and 
putrefactive  inflanniiation,  which  may  follow  attempts  to  evacuate  the 
contents  of  cysts  by  digital  pressure  or  massage  applied  to  thin  skin, 
are  some  of  the  secondary  changes  which  should  be  mentioned.  Fre- 
quently the  hair  follicle  becomes  so  dilated  following  an  inflammation 
or  attempt  at  expression  of  the  contents  of  the  cyst  that  a  wide  defect 


990 


CYSTS,   NOT   INCLUDING  CYSTIC   TUMORS 


Fig.  447. — Enucleated  Sebaceous  Cysts. 


forms,  ill  the  base  of  which  the  dried  and  discolored  atheromatous  masses 
may  be  seen.    A  carcinoma  occasionally  develops  from  a  sebaceous  cyst, 

but  the  diagnosis  cannot  be  made  until  the 
growth  has  ruptured  through  the  cyst  wall 
and  invaded  the  skin.  When  a  cyst  enlarges 
rapidly  and  becomes  ir- 
regular in  form,  suspicion 
of  malignancy  should  be 
aroused. 

3Iost  Common  Sites  for 
Development.  —  Sebaceous 
cysts  develop  most  fre- 
quently in  the  scalp.  They  are  more  common  in  women  than  in  men. 
The  skin  of  the  face  in  the  region  of  the  ear,  of  the  cheek,  eyelids,  neck, 
back,  and  external  genitalia  are  involved  most  commonly  after  the  scalp, 
in  the  order  of  fre- 
quency as  given  here. 
]\Iultiple  atheromas  of 
the  scalp  and  skin  of 
the  back  are  common 
(Fig.  448). 

Age.  —  Atheromas 
have  not  been  ob- 
served in  the  young; 
(never  before  the  fif- 
teenth year — Chiari). 
They  occur  very  fre- 
quently in  the  old. 

Diagnosis.  —  The 
diagnosis  is  easily 
made,  as  the  cysts  are 
round  and  sharply 
defined,  have  smooth 
sui'faees,  are  intimate- 
ly related  to  the  cutis 
covering  them,  move 
freely  with  the  skin 
upon  the  subjacent  tissue,  occur  in  definite  parts  of  the  body,  and 
have  a  slow,  painless  growth,  unless  inflamed  or  undergoing  malignant 
changes.  Small  cysts  have  a  hard,  large  ones  a  doughy  or  fluctuating 
consistency.  Cysts  lying  close  together  may  apparently  communicate 
with  each  other  (Fig.  448). 

'J'he  diagnosis  is  difficult  only  when  no  connection  can  be  demon- 


Fic;.  448. — Multiple  Atheromas  (Fourteen)  of  the  Scalp. 


CYSTS,    NOT    I.NCLI'DIXG   CYSTIC   TUMORS  991 

strated  between  the  cyst  and  the  skin,  and  the  latter  can  be  entirely- 
raised  from  the  surface  of  the  former.  If  this  is  the  case,  the  cyst  may 
be  a  dermoid,  a  subcutaneous  atheroma,  the  duct  of  which  has  been, 
constricted  off,  or  an  epidermoid.  A  positive  clinical  diagnosis  cannot 
be  made  in  these  cases,  and  a  microscopic  examination  is  necessary. 
Papilla?  are  never  found  in  tlie  epithelial  lining  of  an  atheroma,  while 
they  are  usually  present  in  epidermoids. 

Indications  for  Removal — Technic. — The  removal  of  sebaceous  cysts 
may  be  indicated  for  cosmetic  reasons,  because  of  pain  following  inflam- 
mation or  the  beginning  of  malignant  changes.  The  entire  cyst  wall 
must  be  removed  in  order  to  prevent  recurrences.  [In  removing  a 
cyst,  the  latter  should  be  transfixed,  the  cheesy  contents  squeezed  out, 
and  the  cyst  wall  removed  by  grasping  it  and  pulling  it  away  with 
artery  or  tissue  forceps.  In  removing  a  cyst  wall,  the  inspissated, 
stratified  contents  of  the  cyst  should  not  be  mistaken  for  the  epithelial 
lining.] 

In  some  situations  the  cyst  wall  will  have  to  be  dissected  out,  but 
even  in  these  cases  it  is  better  to  transfix  the  cyst  and  deal  with  the 
wall  from  below  ui)ward.  If  the  cyst  wall  has  been  partially  destroyed 
by  suppuration,  it  may  be  necessary  to  remove  the  remnants  of  the  epi- 
thelial lining  with  a  sharp  spoon. 

2,  Mucous  Cysts. — Retention  cysts  not  infrequently  develop  within 
the  mucous  glands.  Small  nndtiple  cysts  or  single  large  growths  may 
develop  after  chronic  inflammation  of  the  nnicous  membrane,  associated 
with  atrophy,  and  in  polypoid  growths  of  the  nose  and  accessory  sinuses. 
Large  solitary  cysts  are  common  in  the  mouth  cavity,  occurring  fre- 
quently upon  the  inner  surfaces  of  the  lips,  especially  of  the  lower  lips 
of  children  and  adults;  in  the  cheeks  and  upon  the  posterior  part  of 
the  lower  surface  and  the  mai'gins  of  the  tongue.  These  cysts  pi'oduce 
round,  painless,  circumscribed  projections,  Avliich  grow  slowly  and  rarely 
become  larger  than  a  bean.  The  mucous  contents  of  the  cysts  shine 
through  the  thinned  nnicous  membrane  which  covers  them,  ^lucous 
cysts  have  thin  Avails  which  are  usually  lined  by  but  a  few  epithelial 
remnants,  as  the  greater  number  of  the  epithelial  cells  are  cast  off  into 
the  cavity  of  the  cysts  and  degenerate. 

Symptoms  develop  only  when  the  mucous  membrane  covering  these 
cysts  is  injured  during  nuistication. 

The  nature  of  the  sharply  delimited  cyst,  which  appears  as  a  vesicle, 
is  usually  easily  recognized.  A  mucous  cyst  may  resemble  a  cystic 
lymphangioma,  but  the  tissues  surrounding  the  latter  usually  contain 
cavernous  tissue  and  are  thickened,  while  the  area  surrounding  the  for- 
mer is  normal.  The  size  of  the  cyst  cannot  be  reduced  by  pn-ssure. 
The  contents  of  a  nuicous  cyst  cannot  be  expressed  by  j)ressure  uidess 


992  CYSTS,   NOT   INCLUDING  CYSTIC  TUMORS 

ruptured,  while  those  of  a  cavernous  haemangioma  or  of  an  aneurysm  of 
one  of  the  labial  arteries  can. 

Removal. — Mucous  cysts  can  be  removed  easily.  The  cyst  wall  is, 
however,  usually  so  thin  that  enucleation  is  impossible,  and  therefore  it 
is  recommended  that  the  external  wall  of  the  cyst,  together  with  mucous 
membrane  covering  it,  be  cut  aAvay  with  curved  scissors  and  that  the 
remainder  of  the  cyst  wall  be  destroyed  with  the  actual  cautery. 

3.  Cysts  of  Salivary  Glands — Eanulw. — Retention  cysts  of  the  sal- 
ivary glands  may  develop  in  the  excretory  ducts  as  well  as  in  the  glands 
proper,  and,  therefore,  cysts  of  the  ducts  are  dififerentiated  from  cysts 
of  the  glands. 

Cysts  develop  most  frequently  in  the  ducts  of  the  submaxillary  and 
parotid  glands  after  injuries,  inflammatory  processes,  and  the  impac- 
tiqu  of  salivary  calculi.  A  long  oval  swelling  develops,  which  gradually 
enlarges,  associated  with  a  swelling  of  the  corresponding  glands  due  to 
the  accumulation  of  saliva.  The  mucous  membrane  covering  such  a  cyst 
may  be  easily  injured,  and  the  first  difficulties  are  usually  experienced 
when  the  cyst  becomes  inflamed  or  becomes  large  enough  to  project 
prominently  into  the  floor  of  the  mouth.  Frequently  these  cysts  rup- 
ture into  the  floor  of  the  mouth,  undergoing  then  spontaneous  cure,  as 
an  internal  salivary  fistula  develops.  If  a  cyst  of  the  parotid  duct  rup- 
tures upon  the  cheek,  and  an  external  salivary  fistula  is  formed,  an 
operation  will  be  required  to  close  it.  Destruction  of  the  salivary  gland 
following  obstruction  of  its  duct  may  end  in  spontaneous  cure. 

The  long  form  and  the  position  of  the  cysts  of  the  excretory  ducts 
of  the  salivary  glands  are  characteristic,  and  enable  one  to  differentiate 
them  with  certainty  from  other  forms  of  cysts. 

Incision  of  the  wall  of  the  cyst,  producing  an  internal  salivary  fistula, 
is  the  treatment  indicated  in  these  cases. 

Cysts  of  the  glands  proper  are  the  sequelte  of  chronic  inflammatory 
processes,  for  the  proliferating  connective  tissues  compress  the  smaller 
ducts  and  occlude  their  lumina.  Usually  many  ducts  are  involved 
simultaneously,  and  as  the  result  of  pressure  atrophy  of  the  tissues 
separating  the  smaller  cysts  a  number  of  the  latter  may  fuse  to  form 
one  large  one.  The  cells  lining  these  large  cysts  gradually  become  flat- 
tened by  pressure,  while  the  connective  tissues  surrounding  them  pro- 
liferate to  form  a  thin  capsule,  which  is  attached  to  the  adjacent  tissues. 
The  formation  of  the  larger  cysts  by  the  coalescence  of  smaller  ones  is 
indicated  by  projections,  resembling  septa,  which  are  found  within  the 
Avails  of  the  former. 

The  majority  of  these  cysts  are  found  within  the  sublingual  gland. 
They  form  the  greater  part  of  those  cysts  in  the  floor  of  the  mouth 
u'liicli  are  classified  as  ranula'.     Cysts  of  the  sublingual  gland  usually 


CYSTS,   NOT   INCLUDING   CYSTIC   TUMORS  993 

first  appear  at  the  side  of  the  frenulum.  As  they  enlarge  they  may  pro- 
duce a  marked  swelling  upon  both  sides  of  it,  which  projects  promi- 
nently into  the  floor  of  the  mouth.  The  cysts  are  usually  covered  by 
a  thin,  tense  mucous  membrane,  while  the  cysts  of  the  submaxillary  and 
parotid  glands,  which  never  become  larger  than  a  walnut,  lie  concealed 
beneath  normal  skin,  to  which  they  are  not  attached.  All  these  cysts 
grow  slowly  and  do  not  give  rise  to  any  marked  symptoms  until  they 
have  reached  considerable  size.  A  clear  fluid  containing  threads  of 
mucus  is  found  in  these  cysts. 

Cysts  of  the  sublingual  gland  are  easily  recognized.  Lipomas  and 
dermoid  cysts  of  the  floor  of  the  mouth,  which  should  be  considered  in 
a  difl'ei'ential  diagnosis,  do  not  have  the  bluish,  transparent  appearance 
so  characteristic  of  ranula?.  Retention  cysts  of  the  ducts  of  submaxil- 
lary glands  have  a  long,  oval  form  corresponding  to  the  position  of  the 
ducts,  which  is  quite  characteristic.  It  is  more  difficult  to  recognize  cysts 
of  the  parotid  and  submaxillary  glands,  and  frequently  a  diagnosis  can- 
not be  made  without  an  exploratory  puncture.  The  cysts  may  be  situ- 
ated in  the  deeper  parts  of  the  enlarged  glands,  and  it  may  be  very 
difficult  in  these  cases  to  difl:'erentiate  retention  cysts  from  true  tumors. 

Complete  removal  of  the  cyst  or  destruction  of  the  entire  wall  is 
the  only  treatment  which  is  at  all  successful.  Incision  alone  is  never 
successful,  as  the  cyst  recurs  as  soon  as  the  incision  heals.  Injection  of 
tincture  of  iodin  may  be  tried  in  the  treatment  of  cysts  of  the  parotid 
gland.  If  the  cysts  are  situated  in  the  submaxillary  or  sublingual 
glands,  complete  extirpation  of  the  cyst  with  the  corresponding  gland 
is  to  be  recommended. 

Cysts  of  the  Glandular  Organs. — Many  of  the  different  forms  of 
retenticm  cysts  which  occur  within  the  different  glands  tire  of  surgical 
importance. 

(i)  detention  Cysts  of  Ihe  Breast. — Two  forms  of  i'(>tention  cysts  are 
found  in  the  female  breast.  The  retention  cyst  containing  milk,  called 
a  galactocele,  follows  the  occlusion  of  the  smaller  or  larger  milk  ducts  of 
the  functionating  breast  by  inflannnatory  processes  or  cicati'icial  changes. 
In  the  other  form  multiple  cysts  develop.  These  are  found  most  fre- 
quently in  old  people,  and  usually  develop  in  both  bi-easts.  The  mul- 
tiple cysts  vary  in  size.  The  majority,  however,  are  small  and  may  be 
easily  recognized  by  their  dark  brown  or  green  color,  when  the  surface 
of  the  breast  is  exposed  or  the  gland  is  incised.  Acc(n-ding  to  Konig, 
these  multiple  cysts  follow  the  occlusion  of  the  finer  ducts  by  a  chronic 
inflammatory  process  which  also  stinnilates  the  epithelium  to  the  pro- 
duction of  a  serous  or  colloid  material.  The  cicati'icial  changes  ending  in 
obliteration  of  the  ducts  also  occur  in  the  involuting  breast.  The  origin 
of  these   cysts  has  not  been  satisfactorily   explained,   and   many — for 


994  CYSTS,  NOT   INCLUDING  CYSTIC  TUMORS 

example,  Schimmelbuseh — believe  that  the  proliferation  of  the  epithe- 
lium lining  the  acini  is  the  primary,  the  cystic  dilatation  the  secondary 
change,  lie  therefore  thinks  that  multiple  cysts  should  be  regarded  as 
eystadenomas. 

(n)  Retention  Cysts  of  the  Testicle. — The  retention  cysts,  which  not 
infrequently  develop  within  the  testicle,  are  known  as  spermatoceles. 
They  are  usually  found  within  the  globus  major  of  the  epididymis  and 
in  the  rete  testis.  As  they  develop  they  displace  the  testicle  downward. 
They  are  regarded  as  retention  cysts  of  the  vasa  efferentia  or  of  the 
aberrant  ducts,  one  extremity  of  which  ends  blindly,  the  other  com- 
municates with  the  duets  of  the  testicle  or  epididymis.  These  cysts 
grow  slowly  without  causing  symptoms  and  vary  in  size  from  a  bean 
to  a  man's  fist.  Frefpiently  spermatozoa  can  be  demonstrated  in  the 
milky  fluid  which  they  contain.  They  may  be  lined  with  cylindrical 
cells  with  or  witlumt  cilia  or  with  flat  epithelium.  These  cysts  are 
usually  secondary  to  obliteration  of  the  ducts  by  inflammatory  processes 
following  gonorrhea. 

(m)  lietcntion  Cysts  of  Pancreas  and  Liver. — Cysts  of  the  pancreas, 
following  occlusion  of  the  larger  ducts  or  their  branches,  or  of  the 
interlobular  ducts  by  interstitial  inflammatory  processes,  are  rare.  Some 
of  the  cysts  found  in  the  liver,  follow  obliteration  of  the  finer  bile 
ducts  by  cicatricial  tissue.  [The  majority  of  the  cysts  found  within  the 
pancreas  and  liver  are  new  growths  and  should  be  classified  with  the 
eystadenomas.] 

{iv)  Retention  Cysts  of  Ductless  Glands. — Retention  cysts  may  de- 
velop in  organs  which  have  no  excretory  ducts.  Cysts  of  the  ovary, 
hydrops  follicularis,  are  common.  These  may  occur  as  multiple  cysts 
in  the  ovary  developing  from  follicles  which  have  not  ruptured.  They 
may  become  as  large  as  a  fist.  Not  infrequently  nudtiple  cysts  develop 
in  the  thyroid  gland  from  the  fusion  of  dilated  follicles  containing 
colloid. 

The  diagnosis  and  treatment  of  cysts  of  the  different  glands  belong 
to  special  surgery. 

(c)  Lymphatic,  Blood,  and  Chylous  Cysts. — It  is  not  to  be  doubted 
that  retention  cysts  occur  in  lymj)hatic  and  blood  vessels,  but  it  is  diffi- 
cult to  recognize  the  causes  of  the  different  forms.  Blood,  lymphatic, 
and  chylous  cysts  are  the  ones  which  follow  the  extravasation  of  blood 
and  lymph  oi*  occlusion  of  the  vessels  by  disease. 

Frequently  blood  cysts  follow  the  extravasation  and  encapsulation 
of  blood  in  the  different  tissues.  Blood  cysts  following  the  extravasa- 
tion of  blood  into  the  peritoneum  or  loose  retro])eritoneal  tissues  after 
subcutaneous  injuries  of  the  abdomen  may  reach  considerable  size. 
Lymphatic  and  chylous  cysts,  caused  by  dilatation  or  bursting  of  the 


CYSTS,   NOT   INCLUDING   CYSTIC  TUMORS  995 

lymphatics  following  occlusion  of  the  thoracic  duct  or  one  of  the  larger 
lymphatic  vessels,  may  also  develop  in  the  mesentery  and  retroperitoneal 
tissues. 

The  rare  congenital  hlood  cysts  of  the  neck,  which  are  the  result  of 
developmental  disturbances  in  the  anlage  of  the  vessels  and  occur  in 
positions  ordinarily  occupied  by  veins,  the  latter  having  failed  to  de- 
velop, are  true  cj'sts.  The  walls  of  these  cysts  correspond  more  or  less 
closely  to  the  walls  of  veins,  and  the  contents  consist  of  altered  blood 
or  of  fresh  blood,  when  the  blind  end  of  an  imperfectly  developed  vein 
forms  a  sac.  Blood  cysts  also  develop  along  the  course  of  the  saphe- 
nous veins,  when  evaginations  in  varicose  veins  become  constricted  off 
from  the  parent  stem. 

True  lymph  or  serous  cysts  are  not  easily  recognized.  The  small 
cysts  are  simple  dilatation  of  lymphatic  vessels,  while  the  larger  cysts, 
if  an  endothelial  lining  is  present,  are  to  be  regarded  as  cystic  lymph- 
angiomas. According  to  Odenius,  however,  cystic  degeneration  does 
occur  in  lymph  nodes  following  lymph  stasis.  Nothing  definite  is  kno\\Ti 
concerning  the  developmental  history  of  the  large  chylous  cysts  which 
are  occasionally  found  in  the  mesentery. 

Multilocular  cysts  of  lymph  nodes,  w^hich  are  found  most  frequently 
in  the  groin,  are  called  lymphadenoceles.  These  cysts  are  found  most 
frequently  in  people  in  the  tropics,  and  are  the  result  of  the  stasis  of 
lymph  and  the  dilatation  of  the  lymph  sinuses  following  infection  with 
the  filaria  sanguinis  Jiominis. 

(4)    PARASITIC   CYSTS 

The  echinococcus  and  cysticercus  appear  in  the  tissues  as  cysts  which 
are  encapsulated  the  same  as  foreign  bodies. 

(a)  Taenia  Echinococcus. — The  ttenia  echinococcus  is  from  4  to  5  mm. 
long  and  possesses  only  four  segments,  of  w^hich  the  most  posterior  sur- 
passes in  length  all  the  rest  put  together.  A  number  of  eggs  are  found 
in  the  last  segment.  The  head  is  provided  with  sucking  disks  and  a 
circle  of  booklets. 

Habitat. — The  taenia  echinococcus  lives  in  the  intcvstinal  canal  of 
dogs.  It  does  not  reach  full  development  in  man,  but  tends  to  the 
formation  of  large  cysts  which  may  seriously  interfere  with  the  function 
of  the  tissues  and  organs  involved. 

When  mature  the  last  segment  becomes  filled  with  ova  which  are 
discharged.  These  find  their  way  into  the  human  stomach  in  water  or 
upon  uncooked  vegetables,  such  as  water  cress,  which  have  been  con- 
taminated with  the  dog's  excreta. 

The  process  of  digestion  sets  the  embryos  free,  and  they  become  at- 


996  CYSTS,   NOT   INCLUDING  CYSTIC   TUMORS 

tached  to  the  gastric  and  intestinal  mncons  m(>nibrane  by  the  sucking 
disks  and  booklets,  and  finally  penetrate  it  to  enter  the  lymphatic  and 
blood  vessels. 

Transportation  of  Embryos  hy  Blood  and  Lymph  Stream. — They  are 
then  carried  by  the  blood  stream  to  the  liver  and  with  the  chyle  through 
the  thoracic  duct  to  the  right  heart  and  the  lungs.  The  liver  and  the 
lungs  act  as  filters,  as  frequently  the  capillaries  are  not  large  enough 
to  permit  of  the  passage  of  the  large  embryos  of  from  25  to  28  fi  in 
diameter.  After  they  pass  through  the  vessel  walls  they  develop  to 
form  large  cysts,  which  may  be  unilocular  or  multilocular.  According 
to  the  investigation  of  Mangold,  Melniko-Raswedenkow,  and  Posselt, 
it  depends  upon  the  species  of  the  worm  whether  unilocular  or  multi- 
locular cj'sts  develop. 

Walls,  Lining,  and  Contents  of  Cysts. — The  embryo  which  has  pene- 
trated the  tissues  slowly  becomes  transformed  into  a  small  cyst  which 
in  the  course  of  six  months  attains  the  size  of  a  hazelnut.  The  wall  of  a 
hydatid  cyst  consists  of  a  lamellar,  stratified  elastic  membrane  without 
cells  (cuticula),  the  inner  surface  of  which,  the  so-called  parenchyma 
layer,  contains  muscle  fibers,  blood  vessels,  and  the  vesicular,  germinal 
cells. 

Echinococcus  cysts  are  filled  with  a  clear,  watery  fluid  which  contains 
no  albumin,  and  therefore  is  not  coagulated  by  heat.  The  fluid  contains 
principally  sodium  chlorid,  calcium  oxalate,  and  a  toxalbumin.  The  lat- 
ter probably  produces  the  toxic  symptoms  almost  always  accompanied 
by  urticaria,  which  follow  the  rupture  of  a  cyst.  Scoleces  and  booklets 
may  be  demonstrated  microscopically  in  this  fluid. 

Daughter  and  Granddaughter  Cysts. — When  the  embryo  lodges  in 
some  viscus  it  changes  into  a  cyst  incapable  of  active  motion.  When  the 
cyst  has  reached  the  size  of  a  walnut  approximately  (sometimes  earlier), 
there  are  formed  from  the  parenchymatous  layer  small  brood  capsules, 
the  delicate  wmIIs  of  which  likewise  consist  of  two  layers,  an  inner 
cuticular  layer  and  an  outer  parenchymatous  layer.  Upon  these  brood 
capsules  the  small  h(>ads  or  scoleces  develop  in  very  large  numbers. 
According  to  Leuckart,  they  grow  out  of  hollow  sacs  which  bulge  out 
fiom  the  external  wall  of  the  brood  capsules.  Brood  capsules  are  formed 
in  the  same  way  as  the  primary  cysts  which  develop  from  the  six-hooked 
embryos.  The  daughter  cysts  which  float  free  in  the  mother  cyst  may 
be  very  numerous,  often  as  many  as  a  thousfind  being  found.  They  vary 
in  size  and  sometimes  contain  granddaughter  cysts. 

If,  after  the  development  of  brood  capsules  and  scoleces,  daughter 
cysts  do  not  foi-m,  the  echinococcus  remains  a  simple  cyst  (acephalo- 
cyst),  and  is  differentiated  from  the  echinococcus  hydatidosus,  which  is 
filled  with  daughter  cysts. 


CYSTS,   NOT   INCLUDING   CYSTIC  TUMORS  997 

Reaction  of  Surrounding  2'issucs — h'upturc  of  Cysts. — The  siirroiiiul- 
ing  tissues  form  a  connective-tissue  capsule  for  the  cysts,  which  in  the 
course  of  years  becomes  quite  thick.  The  capsule  covering  the  part 
of  the  cyst  which  is  exposed  upon  the  surface  of  an  organ  is  so  thinned 
that  it  breaks  easily.  If  the  cyst  ruptures,  as  frequently  occurs,  the 
daughter  cysts  aiul  scoleees  are  scattered;  for  example,  if  a  cyst  rup- 
tures into  the  peritoneal  cavity  the  scoleees  and  daughter  cysts  become 
attached  to  the  intestinal  loops  and  numerous  new  cysts  develop.  If 
adhesions  occur  the  cysts  may  rupture  into  the  stomach,  intestine,  or 
trachea. 

Infection  of  Cysts. — These  cysts  may  become  infected,  undergoing 
suppurative  or  putrefactive  changes.  Rupture  may  then  be  followed 
by  pleuritis  or  peritonitis,  depending  upon  the  situation  of  the  cyst. 
Occasionally  a  cyst  ruptures  into  the  inferior  vena  cava,  causing  fatal 
embolism. 

Dcatii  of  EcJiinococcus  icitJi  Spontaneous  Cure. — Death  of  the  echino- 
coccus  is  a  fairly  frecpient  occurrence.  It  is  observed  when  the  cyst  is 
small  or  after  some  disease  of  the  host.  The  cyst  then  contracts  to  form 
a  fatty  or  chalky  mass,  the  nature  of  which  can  be  recognized  for  a 
long  time  by  booklets  and  remnants  of  membrane. 

Multilocular  and  Unilocular  Echinococcus. — The  multilocular  echino- 
coccus  always  develops  small  cysts  which  vary  in  size  from  that  of  a 
millet  seed  to  that  of  a  pea.  These  cysts  are  always  present  in  large 
numbers.  This  echinococcus,  which  is  found  most  frequently  in  the 
liver,  lungs,  and  bones,  appears  as  a  firm  tumor  possessing  upon  section 
an  alveolar  structure,  as  it  is  composed  of  man.v  small  cavities  sur- 
rounded by  thick,  compact,  connective  tissue.  The  contents  of  the  cavi- 
ties are  gelatinous  and  transparent  or  of  a  semisolid,  sometimes  caseous, 
consistenc}^  As  a  result  of  regressive  changes  in  the  thick  connective 
tissues,  developing  secondary  to  the  irritation  of  the  cyst,  large  cystic 
cavities  and  extensive  calcified  areas  composed  of  degenerated  connective 
tissues  and  dead  cysts  may  form.  The  tissues  of  cysts  developing  in  the 
liver  are  often  bile-stained.  These  cysts  undergo  an  exogenous  sprout- 
ing, invading  the  lymphatic  spaces  and  vessels  and  producing  a  pressure 
atrophy  of  the  viscera  and  tissues  in  which  they  are  deposited.  The  cavi- 
ties following  regressive  changes  may  rupture  into  the  tissues  adjacent 
to  the  organ  primarily  involved,  or  into  a  neighboring  viscus  which 
has  gradually  undergone  atrophy  as  a  result  of  pressure  exerted  by  the 
cyst. 

The  two  forms  ditil'er  in  their  geographical  distribution.  The  multi- 
locular echinococcus  is  found  most  frequently  in  South  Germany  and 
Switzerland,  where  they  also  occur  in  cattle,  more  rarely  in  swine.  The 
unilocular  form,  on  the  other  hand,  occurs  most  frequently  in  North 


998 


CYSTS,   NOT   INCLUDING  CYSTIC  TUMORS 


and  East  Germany,  but  also  occurs  over  the  whole  of  Europe,  in  South 
Australia,  Algiers,  Egypt,  Cape  Colony,  and  is  especially  common  in 
Iceland. 

The  disease  is  extensively  distributed  among  domestic  animals,  and 
among  dogs  in  countries  in  wliich  cattle  are  numerous.  They  have 
abundant  opportunities  for  taking  up  the  echinococcus,  and  therefore 

the  danger  of  in- 
fecting the  people  is 
great. 

Organs  and  Tis- 
sues Most  Frequent- 
ly Involved.  —  The 
echinococcus  may  de- 
velop in  any  part  of 
the  body.  The  liver 
and  lungs  are  most 
frequently  involved, 
however,  as  the  em- 
bryos penetrate  the 
blood  or  lymphatic 
vessels  of  the  intes- 
tines and  are  deposit- 
ed secondarily  in  the 
viscera  above  men- 
tioned. Infection  of 
the  kidneys,  spleen, 
peritoneum,  muscles, 
bone,  skin,  mammary 
and  thyroid  glands 
occurs,  but  is  much 
less  common. 
rrognosis. — The  prognosis,  like  the  symptoms,  depends  entirely  upon 
the  position  of  the  cyst  or  cysts.  Deep  cysts,  when  they  rupture  or 
become  infected,  are  much  more  dangerous  than  the  superficial  ones.  In- 
volveirient  of  the  vertebne  and  pelvic  bones  is  more  fatal  than  that  of 
other  bones,  as  cysts  of  the  vertebra?  produce  pressure  upon  the  cord. 
Cysts  of  the  pelvic  bones  frequently  become  infected  and  suppurate. 

Symptoms. — Frequently  the  symptoms  following  the  development 
of  cysts  in  deep  viscera  (liver,  lung,  spleen,  kidney)  are  indefinite.  The 
symptoms  first  become  definite  when  the  cyst  becomes  large  enough  to 
exert  i)i'essHre  iipon  neigliboring  structures,  suppurates  or  ruptures. 
Infection  followed  by  suppuration  is  accompanied  by  severe  pain,  fever, 
rapid  loss  of  strength,  progressive  inflammation  of  the  organ  involved, 


Fig.  449. — Large  Echinococcus  Cyst  in  the   Muscles  of 
THE  Back  (Echinococcus  Hydatidosus). 


CYSTS,   NOT   INCLUDING  CYSTIC  TUMORS  999 

localized  or  proiircssivc  suppuration  in  the  poritoneal  or  pleural  cavi- 
ties, rupture  into  neighboring  organs  ( stomach,  intestines,  urethra, 
bronchi),  or  through  the  skin.  Rupture  of  the  cyst,  often  produced  by 
trauma,  is  followed  by  toxic  symptoms  (with  urticaria),  and  the  diffu- 
sion of  brood  capsules  and  scoleces  from  which  new  cysts  may  develop. 
Rupture  is  an  especially  dangerous  accident  when  the  peritoneum  is  in- 
volved. Death  follows  more  frequently  than  spontaneous  healing,  rup- 
ture or  suppuration  of  a  cyst  which  is  deeply  situated. 

Diagnosis. — The  diagnosis  belongs  to  the  province  of  special  surgery, 
as  the  symptoms  are  those  which  follow  interference  with  the  function 
of  the  organ  involved.  It  should  be  mentioned  that  exploratory  punc- 
ture should  be  omitted  when  the  cyst  is  adjacent  to  the  pleura  or  peri- 
toneum, as  the  cyst  may  be  ruptured  and  brood  capsules  and  scoleces 
may  be  diffused. 

The  external  forms  of  echinocoecus — those  of  the  subcutaneous  tis- 
sues, muscles,  intermuscular  connective  tissues,  and  superficial  organs — 
appear  as  fluctuating  growths  which  enlarge  very  slowly,  often  inter- 
mittently, and  may  exist  for  a  ninnber  of  years  Avithout  causing  symp- 
toms. The  surface  of  the  swelling  is  smooth  or  nodular,  when  the  brood 
capsules  can  be  pali)ated.  A  cyst  may  become  as  large  as  a  child's  head 
or  larger.  The  swelling  is  round  or  influenced  by  surrounding  tissues, 
especially  when  it  develops  in  the  loose  connective  tissues  between  mus- 
cles or  along  large  blood  vessels.  Even  unilocular  cysts  are  firmly  at- 
tached by  their  connective-tissue  capsules  to  the  surrounding  tissues, 
so  that  the  overlying  skin  cannot  be  raised  when  th(^  cysts  are  super- 
ficial, or  the  muscles  separated  from  them  when  they  arc  deep.  The  cysts 
are  usually  well  defined,  but  can  only  be  displaced  with  the  surrounding 
tissues. 

Tlie  external  forms  are  found  most  frequently  in  the  trunlc  and 
neck,  the  lumbar  region,  the  abdominal  wall,  the  axillary  fossa\  and  the 
inguinal  regions.  The  spaces  occupied  by  the  vessels  of  the  neck  are 
most  frequently  involved.  Of  the  dift'erent  glands,  the  thyroid  <ind  the 
mannnary  are  most  fre((uently  affect(^d.  Cysts  of  the  extremity  are 
found  most  frequently  in  the  internal  bicipital  sulcus,  in  the  region 
of  the  adductors  of  the  thigh,  and  in  the  ])oplit('al  fossa.  In  the  head 
they  develop  most  frecpiently  in  the  tempoi-al  and  masseter  nnisclas  and 
the  orbit. 

The  diagnosis  of  the  external  forms  of  echinocoecus  is  usually  made 
by  exclusion  and  by  the  peculiarities  of  the  parasitic  cysts. 

All  fluctuating,  circumscribed  tumors,  chronic  abscesses,  and  cysts 
which  occur  in  the  area  involved,  such  as  cystic  l.^nnphangiomas,  lipomas, 
dermoids,  hygromas,  cysts  of  the  mammary  and  thyroid  glands,  ranula, 
and  tuberculous  abscesses,  must  be  considered  and  excluded.     The  so- 


1000  CYSTS,   NOT   INCLUDING  CYSTIC  TUMORS 

called  hydatid  fremitus,  which  is  elicited  by  tapping  the  cyst  wall  and 
is  supposed  to  be  characteristic,  can  be  elicited  only  in  the  large  uni- 
locular C3'sts.  The  fremitus  is  probably  due  to  the  movement  of  the 
daughter  cysts  on  one  another.  Aspiration  of  the  cyst  and  examina- 
tion of  the  fluid  is  naturally  the  most  positive  diagnostic  method. 
This  procedure,  of  course,  is  much  less  dangerous  when  the  cyst  is  situ- 
ated in  the  soft  tissue  than  when  it  is  situated  in  the  pleural  or  peri- 
toneal cavities. 

A  positive  diagnosis  is  impossible  when  suppuration  within  the  cyst 
or  a  pericystic  phlegmon  develops.  The  nature  of  the  process  in  these 
cases  is  generally  unsuspected  until  degenerating  cysts  and  shreds  of 
the  cyst  wall  are  revealed  by  incision. 

E.ckinococcus  of  bone  is  not  very  common.  Only  one  hundred 
and  two  cases  have  been  reported  up  to  the  present  time  (Frangen- 
heim). 

The  lesions,  like  embolic  infections,  are  situated  most  frequently  in 
the  spongy  ends  of  long  bones.  An  old  fracture  or  a  part  of  a  bone 
recently  injured  are  most  commonly  attacked,  the  abnormal  vascular 
relations  in  the  callus  and  the  lacerations  of  vessels  produced  by  an 
injury  providing  favorable  conditions  for  the  deposition  and  growth 
of  the  parasite.  The  pelvic  bones  and  vertebra?  are  next  most  frequently 
involved  after  the  long  bones.  Isolated  cases  of  involvement  of  the 
skull  bones  followed  by  rupture  into  the  sphenoidal  and  frontal  sinuses 
or  into  the  cranial  cavity,  of  the  ribs,  sternum,  scapula,  and  phalanges 
have  been  observed. 

The  multilocular  form  develops  in  bones  more  frequently  than  the 
unilocular.  In  the  beginning,  cysts  the  size  of  a  pinhead  or  pea  develop 
in  the  spongy  tissue.  As  a  result  of  the  atrophy  of  the  bony  trabecula? 
and  necrosis  of  the  surrounding  spongy  tissue,  large  irregular  cavities 
filled  with  yellow  or  white  fluid,  which  contain  sequestra  of  bone,  bone 
sand,  cysts,  detritus,  and  cholesterin,  are  formed. 

The  cysts  may  be  unobserved  for  a  number  of  years  and  increase 
in  size  without  producing  any  symptoms,  or  the  latter  may  consist 
merely  of  mild  mi  aerating  pains  and  a  sense  of  weariness.  The  bone  is 
destroyed  gradually'',  and  usually,  even  when  the  cyst  extends  to  the 
periosteum,  there  is  no  periosteal  bone  formation  to  strengthen  the  part 
of  the  bone  destroyed  by  the  enlargement  of  the  cysts.  As  a  result 
the  bone  involved  becomes  very  thin,  and  spontaneous  fracture  of  the 
long  bones  or  rupture  of  a  puriform  mass  together  with  cysts  into  the 
soft  tissues  may  be  the  first  indication  of  the  disease.  The  symptoms 
of  echinococcus  disease  of  the  vertebra?  are  those  of  compression  mye- 
litis, caused  by  the  destruction  of  the  bodies  of  the  vertebra  involved 
and  the  development  of  extradural  cysts.     Flat  bones,  when  involved, 


CYSTS,   NOT   L\X^LUDIXG   CYSTIC   TUMORS  1001 

become  expanded,  and  "  parchment  crackling  "  or  fluctuation  can  be 
elicited  by  pali)ati(m. 

If  an  echinoeoecus  cyst  situated  in  an  epiphysis  ruptures  into  a  joint, 
a  large  part  of  the  latter  is  destroyed  and  a  subluxation  develops.  The 
accumulation  of  material  resembling  that  found  in  an  abscess  precedes 
rupture  through  the  skin,  which  is  followed  by  chronic  fistula. 

The  diagnosis  of  echinoeoecus  disease  of  bone  is  most  difficult.  The 
symptoms  are  so  slight  and  indefinite  and  the  disease  so  rare  that  a 
positive  diagnosis  is  fre(iuently  not  made  until  an  operation  is  per- 
formed. Kiister,  for  example,  during  an  operation  for  pseudarthrosis 
which  followed  a  second  fi-acture  of  the  humerus,  found  an  echinoeoecus 
cyst.  If  a  spontaneous  fracture  occurs,  a  myelogenous  sarcoma,  a  tuber- 
culous abscess,  and  gummata  must  be  considered  in  determining  the 
cause.  If  these  can  be  excluded  and  there  is  no  reactive  proliferation 
of  bone,  it  is  probable  that  an  echinoeoecus  cyst  is  present.  The  findings 
elicited  by  palpation  and  an  X-ray  examination  are  very  helpful.  Ab- 
scesses and  fistula?  suggest  chronic  suppurative  or  tuberculous  osteo- 
myelitis. Even  bacteriological  examination  of  the  pus  is  not  always 
positive,  as  the  necrotic  masses  in  a  cyst  frequently  become  infected  with 
pyogenic  bacteria.  According  to  von  Bergmann,  the  presence  of  numer- 
ous crystals  of  cholesterin  in  the  aspirated  fluid  is  the  most  important 
and  positive  finding  in  these  cases. 

Treatment. — In  the  treatment  of  echinoeoecus  cj^sts  an  attempt  should 
be  made  to  remove  completely  the  cyst  together  with  the  capsule,  and 
to  reestablish  normal  conditions. 

The  unilocular  cysts  situated  superficially  are  most  easily  removed. 
Frequentl}^  cysts  which  involve  the  peritoneum,  mesentery,  and  omen- 
tum can  be  completely  removed.  When  the  cysts  involve  large  viscera 
or  large  areas  of  the  peritoneum  or  pleura,  the  haMiiorrhage,  following 
attempts  at  enucleation,  is  so  severe  that  radical  removal  is  impossible. 

In  these  cases  one  must  be  content  with  incision  and  removal  of  the 
contents  of  the  cyst  after  the  cyst  has  been  exposed  and  sutui'ed  to  the 
edges  of  the  wound.  Drainage  must  then  be  continued  for  a  number  of 
months  before  healing  is  complete.  The  operation  may  be  done  in  one 
sitting,  that  is,  the  cyst  may  be  opened  immediately  after  it  is  sutured 
into  the  wound,  care  being  exercised  to  prevent  the  fluid  from  flowing 
back  into  the  pleura  or  peritoneal  cavities ;  or  in  two  sittings,  the  incision 
of  the  cyst  being  postponed  until  firm  adhesions  have  been  established 
between  the  cyst  wall  and  the  edges  of  the  wound. 

As  the  period  required  for  healing  after  incision  as  above  described 
is  prolonged,  the  operation  has  been  somewhat  modified.  Bobrow  and 
Garre  incise  the  capsule,  after  the  surrounding  tissues  have  been  care- 
fully protected,  remove  the  contents  of  the  cysts,  and  as  much  as  pos- 
64 


1002  CYSTS,   NOT   INCLUDING   CYSTIC   TUMORS 

sible  of  the  membrane  lining  the  inner  snrface.  The  parts  of  the  cap- 
sule which  can  be  easily  separated  are  then  cut  away.  The  cyst  is  then 
closed  by  a  double  row  of  sutures  and  allowed  to  sink  back  into  the 
abdomen.  In  order  to  protect  against  suppuration,  and  if  recurrence  is 
feared,  the  cyst  may  be  sutured  to  the  abdominal  wall.  If  the  cavity 
of  the  cyst  and  the  transudate  which  forms  remain  sterile,  the  cyst 
gradually  undergoes  cicatricial  contraction. 

The  removal  of  a  multilocular  echinococcus  cyst  from  a  viscus  is 
very  similar  to  the  operations  performed  for  malignant  growths,  and 
should  be  attempted  only  when  the  cyst  is  small  (e,  g.,  removal  from 
the  liver  by  cuneiform  resection).  The  kidney,  likewise  the  spleen  when 
involved,  should  be  removed.  Incomplete  operations,  such  as  incision 
or  removal  of  part  of  the  cyst,  are  not  successful. 

Cysts  of  hone  which  are  small  may  be  easily  exposed  and  satisfac- 
torily removed  by  chiseling  away  the  bone  and  curetting  out  the  cysts. 
If  the  cysts  are  large  and  the  bone  has  been  extensively  destroyed,  re- 
section should  be  considered ;  if  the  cyst  has  become  infected  and  the 
general  condition  of  the  patient  is  poor,  amputation. 

Prophylaxis  is  of  great  importance.  People  who  keep  dogs  should 
exercise  great  care.  The  segments  of  the  echinococcus  containing  eggs 
are  discharged  in  the  faeces  and  the  dog's  nose  may  easily  become  in- 
fected. It  is  as  dangerous  to  allow  a  dog  to  lick  the  hands  and  face 
as  it  is  to  use  the  plates  from  which  a  dog  has  eaten.  It  is  important 
to  keep  dogs  aAvay  from  slaughter-houses,  as  they  may  become  infected 
by  eating  material  infected  with  echinococcus,  and  the  disease  may  be 
spread  in  this  way. 

(b)  Cysticercus  Cellulosae. — "  The  cyst  provided  with  a  tapeworm 
head  is  known  as  a  '  mcasle  '  or  cysticercus  celluloscB.  The  scoleces,  when 
fully  developed,  possess  a  circle  of  hooks,  suckers,  a  water  vascular  sys- 
tem, and  numerous  calcareous  bodies  in  their  parenchyma.  If  they  get 
into  the  human  stomach  the  cyst  is  dissolved,  and  there  develops,  through 
formaticm  of  segments,  a  new  chain  of  proglottides,  a  new  Taenia 
solium." — Ziegler's  "  General  Pathology,"  pp.  555-556. 

The  eggs  of  the  tapeworm,  derived  from  animals  or  man  or  from 
the  pati(Mit  himself,  may  be  carried  by  infected  drink  or  food  or  by 
unclean  lingers  into  the  mouth,  reaching  eventually  the  stomach,  where 
the  capsule  surrounding  them  is  digested  by  the  gastric  juice.  The  em- 
bryos are  then  carried  by  the  lymphatic  and  blood  vessels  to  different 
parts  of  the  body,  where  they  are  deposited.  They  develop  after  some 
weeks  (about  nine)  to  form  cysts  (cysticercus)  the  size  of  a  pea  or 
cherry.  These  cysts  remain  viable  for  a  number  of  years,  and  after 
death  of  the  scolex  cicatrize  and  become  calcified.-  Occasionally  cysts 
developing  from  the  Ta2nia  saginata  are  found  in  man. 


CYSTS,    NOT    INCLUDING    CYSTIC   TUMORS  1003 

Wherever  the  cysticercus  is  deposited  a  mild  intlanmiatioii  develops, 
which  leads  to  a  thickoning  of  the  connective  tissues  surrounding  it. 
The  cysticerci  lying  in  loose  tissue  may  migrate  by  their  own  movement. 

The  cysticercus  develops  most  conniionly  in  young  people.  A  large 
number  of  cysts,  from  100  to  1.000,  may  develop. 

Muscles,  subcutaneous  tissues,  the  brain,  and  eye  are  most  frequently 
involved.  The  liver  and  lung  are  more  rarely  attacked.  Cysticercus 
disease  of  bone  has  been  observed  but  twice. 

The  symptoms  naturally  depend  upon  the  position  of  the  cysts. 
Cysticercus  disease  of  nuiscle  and  of  the  subcutaneous  tissue  is  charac- 
terized by  the  development  of  round,  firm  nodules,  which  never  become 
larger  than  a  hazelnut.  The  nuisclcs  when  involved  l)ecome  weak  and 
there  is  general  muscular  pain.  If  the  cysts  rest  upon  nerves,  paralysis, 
M'cakness,  and  neuralgia  develop.  If  but  a  single  cyst  develops,  it  may 
be  easily  confused  with  a  small  tumor.  Eelatively  frequently  the  brain 
and  its  membrane,  more  rarely  the  spinal  cord,  are  involved  in  cysti- 
cercus disease,  which  occurs  in  these  structures  in  a  peculiar  foi-m, 
namely,  in  the  form  of  cysts  held  together  so  as  to  resemble  grapes 
{cysticercus  racemosus) .  The  cysts  may  produce  no  symptoms,  or,  de- 
pending upon  their  position,  the  symptoms  of  cortical  epilepsy,  or  those 
of  a  tumor  of  the  brain  or  spinal  cord.     They  may  cause  death. 

Cysticercus  of  the  eye  concerns  the  ophthalmologist.  The  cysts  may 
develop  in  the  orbit,  the  vitreous  humor,  beneath  the  retina,  or  con- 
junctiva, or  in  the  anterior  chamber,  and  cause  destruction  of  the  bulb. 

The  treatment  consists  of  early  removal  of  the  cysts  which  are  caus- 
ing the  trouble. 

The  frequency  of  the  disease  has  decreased  with  the  decrease  in  the 
frequency  of  tapeworm  disease  which  has  followed  the  inspection  of 
meat,  and  the  improvement  in  the  methods  of  treating  tapeworms. 

Literature. — Aschoff.  Ergobnisse  der  allgemeiiien  Pathologie  von  Lubarsch  und 
Ostertag.  2.  Jahrgang,  Wiesbaden,  1897. — Askunazy.  Ein  Fall  von  Cysticerken- 
bildung  an  der  Gehirnbasis  mit  Arteritis  obliterans  cerebralis.  Zieglers  Beitr.  z.  path. 
Anat.,  Bd.  7,  1890,  p.  83. — v.  Bergmann.  Ueber  Echinokokken  der  langen  Rohren- 
knochen.  Arbeiten  aus  v.  Bergmanns  Klinik,  Bd.  2,  1887,  p.  1; — Handb.  d.  prakt. 
Chir.,  3.  Aufl.,  Bd.  I,  p.  26,  Pneumatocele  cranii. — Chiari.  Ueber  die  Genese  der 
Atheromzysten  der  Haut  und  des  Unterhautzellgewebes.  Zeitschr.  f  Hcilk.,  Bd.  12, 
1891,  p.  189. — Dannielsen.  Der  Cysticercus  cellulosaj  im  Muskel.  Beitr.  z.  klin. 
Chir.,  Bd.  44,  1904,  p.  238. — Fischer.  Die  Krankheiten  der  Lyinphgefiisse,  Lj'mph- 
driisen  und  Blutgefasse.  Deutsche  Chir.,  1901,  Lymphadenozele,  p.  129. — Gangolphe. 
Maladies  des  os.  Paris,  1894. — Frangenheim.  Die  chir.  wichfigen  Lokalisationcn  des 
Echinokokkus.  Sammlung  klin.  Vortriige,  1906,  Nos.  419-420; — Die  chir.  wichtigen 
Lokalisationen  der  tierischen  Parasiten  u.  s.  w.  Ihid.,  No.  424. — Garrv.  Ueber  neue 
Operationsmethoden  des  Echinokokkus.  Beitr.  z.  klin.  Chir.,  Bd.  24,  1899,  p.  227. — 
Geridatws.  Das  Vorkomnien  von  multiplen  Muskelechinokokken,  nebst  licnierkungen 
iiber  die  Verbreitung  der  letzteren  im  Organismus.     Deutsche  Zeitschr.  f.  Chir.,  Bd.  48, 


1004  CYSTS,   NOT   INCLUDING  CYSTIC   TUMORS 

1898,  p.  372. — Gross.  Die  Lymphangiektasie  der  Leiste  u.  a.  I.  Die  Lehre  der  Adeno- 
lymphozele.  Arch.  f.  klin.  Chir.,  Bd.  76,  1905,  p.  778. — Hirschberg.  Cysticerken  im 
Auge.  Eulenburgs  Realenzyklopiidie,  1885. — Fritz  Konig.  Beitrag  zur  Anatomie  der 
Dermoid-  and  Atheromzysten  der  Haut.  Arch.  f.  Chir.,  Bd.  48,  1894,  p.  184. — Kilttner. 
Zysten  der  Speicheldriisen.  Handbuch  d.  prakt.  Chir.,  2.  Aufl.,  Bd.  1,  j).  666. — Madelung. 
Beitrag  zur  Lehre  von  der  Echinokokkenkrankheit.  Stuttgart,  1885.— Mangold. 
Ueber  den  multilokultiren  Echinokokkus  und  seine  Taenie.  Berk  khn.  Wochenschr., 
1892,  p.  21. — Marchaml.  Zyste.  In  Eulenburgs  Realenzyklopiidie,  Bd.  5,  1895,  p. 
256.^Melnikow-Raswedenkow.  Studien  iiber  Alveolarechinokokkus.  Zieglers  Beitr. 
z.  path.  Anat.,  Bd.  4,  SuppL,  1901. — Mennicke.  Ueber  2  Falle  von  Cysticercus  race- 
mosus.  Ibid.,  Bd.  21,  1897,  p.  243.- — -Odenius.  Ueber  einfache  zystische  Degenera- 
tion d.  Lymphdriisen.  Virchows  Arch.,  Bd.  155,  1899,  p.  465. — Posselt.  Die  Stellung 
des  Alveolarechinokokkus.  Mi'nichn.  med.  Wochenschr.,  1906,  p.  537; — Die  geogra- 
phische  Verbeitung  des  Blasenwurmleidens.  Stuttgart,  1900. — Riemann.  Ueber  die 
Keimzerstreuung  des  Echinokkokus  im  Peritoneum.  Beitr.  z.  klin.  Chir.,  Bd.  24,  1899, 
p.  187'.— Speckert.  Ein  Fall  von  Chyluszyste.  Arch.  f.  klin.  Chir.,  Bd.  75,  1905,  p.  998. 
H.  Strom.  Ueber  Pneumatocele  cranii  supramastoidea.  Zentralbl.  f.  Chir.,  1903,  p. 
1309. 


APPENDICES 


APPENDIX    I 

DIRECT   TRANSFUSION   OF   BIjOOD 

The  transference  of  whole  or  modified  blood,  by  various  methods, 
for  numerous  purposes,  from  an  individual  of  the  same  or  of  an  alien 
species  to  another  has  been  practiced  in  many  parts  of  the  world  for  at 
least  four  centuries.  The  greater  part  of  it  was  done  crudely  and  em- 
pirically before  the  development  of  chemistry,  physiology,  pathology, 
and  bacteriology,  and  before  the  period  of  good  hospitals  and  surgical 
instruments.  There  were  many  accidents  due  to  infection,  clotting  of 
the  blood,  the  use  of  alien  blood,  and  unfortunate  selecticm  of  cases ;  so 
that  with  the  advent  of  normal  saline  solution  as  a  substitute  for  blood, 
transfusion  of  the  latter  was  no  longer  practiced. 

Crile  in  1898  took  up  the  work  again,  using  the  mctliod  introduced 
by  Mosso.  This  method  proved  to  be  impractical,  and  the  work  lapsed 
until  the  work  of  Payr  and  Carrel  and  Guthrie  gave  better  methods. 

From  clinical  and  experimental  research  Crile  has  come  to  the  con- 
clusion that  the  vascular  systems  of  two  patients  may  be  united  so  that 
intima  comes  in  contact  with  intima  only.  This  may  be  accomplished 
by  the  special  anastomosis  tube  devised  by  Crile,  which  is  a  modilieation 
of  the  magnesium  tube  introduced  by  Payr  for  arterial  anastomosis,  or 
by  suture  accortling  to  Carrel.  The  tube  devised  by  Crile  is  made  of 
(ierman  silver  and  is  provided  with  two  grooves  upon  its  outer  surface. 
The  vessel  is  drawn  through  this  tube  and  everted  so  that  the  intima 
is  on  the  outer  side.  The  vessel  is  then  tied  into  the  second  groove, 
and  the  tube  with  intima  on  the  outer  side  is  then  introduced  into  the 
vessel  with  which  the  anastomosis  is  to  be  made.  Intima  is  thus  brought 
in  contact  with  intiuia,  and  there  is  no  foreign  body  in  the  blood  stream. 

The  blood  may  be  transferred  without  clotting,  the  use  of  the  radial 
artery  of  the  donor  and  any  superficial  vein  of  tlic  recipient  yields  the 
best  results,  the  operation  may  be  done  painlessly,  the  blood  lost  by 
the  donor  is  restored  in  from  four  to  five  days,  and  the  amount  trans- 
ferred is  under  the  innnediate  control  of  the  operator.  The  rate  of 
transference  should  be  gauged  carefully  within  the  limits  of  physiologic 
safety. 

1007 


1008  APPENDIX  I 

Transfusion  Cannula. — The  first  model  for  the  transfusion  cannula 
was  suggested  to  Crile  by  Dr.  Mixter  in  December,  1906.  Dr.  Mixter 
designed  and  constructed  a  splendid  model  made  of  two  parts.  Payr's 
magnesium  tube  gave  some  good  suggestions  as  well.  The  cannula  now 
in  use  answers  the  purpose  splendidly,  and  was  developed  in  its  present 
form  after  more  than  twenty  various  models  were  made. 

Management  and  Technic  of  Operation. — A  suitable  donor  is  usu- 
ally readily  obtained.  "We  use  both  men  and  women.  In  cases  in  which 
no  immediate  emergency  exists  the  most  suitable  subject  is  singled  out 
from  among  the  relatives  and  friends.  He  is  approached  tactfully,  the 
most  opportune  time  being  just  after  he  has  left  the  bedside  of  the 
patient.  The  gravity  of  the  patient's  condition  and  the  only  means  of 
relief  are  carefully  detailed,  the  painlessness  of  the  procedure  to  both 
donor  and  recipient  being  assured.  Almost  invariably  a  voluntary  sug- 
gestion to  serve  as  donor  results.  Indeed,  frequently  an  entire  family 
and  friends  have  offered  their  services. 

Our  only  difficulty,  thus  far,  has  arisen  among  ward  patients  who 
have  a  certain  amount  of  distrust  of  surgeons  and  hospitals.  Among 
these  patients,  however,  I  have  experienced  but  one  refusal,  that  being 
in  the  case  of  foreign  parents  of  a  child  of  nine,  Avhose  legs  had  been 
crushed,  the  argument  being  that  the  child  was  not  worth  saving.  In 
two  other  instances  the  donors  were  hired.  In  these  cases  the  commer- 
cial attitude  was  apparent  and  the  donors  were  not  as  tractable  as  those 
who  responded  to  the  appeal  of  sentiment.  A  careful  investigation  as 
to  the  health  of  the  donor,  both  as  to  whether  or  not  it  is  advisable  to 
remove  blood  and  whether  or  not  there  is  any  disease  which  might  be 
transmitted,  is  always  made. 

When  there  is  time  htemolysis  observations  are  obtained  from  the 
proposed  donor  and  the  recipient.  This  test  requires  about  twenty-four 
hours.  By  making  the  haemolysis  test  of  the  proposed  donor  and  of  the 
recipient  various  blood  reactions  may  be  obviated.  Agglutination  may, 
I  think,  M'ith  safety  be  disregarded. 

The  operating  room  should  be  equipped  with  two  tables,  preferably 
of  the  kind  which  permits  of  a  change  of  posture  from  head-up  to  head- 
down.  The  patients  are  given  pillows  in  order  to  be  made  as  comfort- 
able as  possible,  and  are  so  arranged  that  the  left  arm  of  each  may  be 
used.  '■J''he  donor  should  be  placed  on  th(>  table  so  that,  if  necessary,  the 
Trendelenburg  position  may  be  utilized.  The  recipient,  if  both  postures 
are  not  available,  should  be  arranged  so  that  the  reverse  Trendelenburg 
may  be  given.  This  permits  the  better  management  of  a  possil)le  dila- 
taticm  of  the  heart  oi"  the  recipient  and  of  a  cerebral  anu'inia  of  the 
donor.  I  have  found  that  it  is  a  great  aid  to  have  a  trained  operative 
staff,  so  that  the  many  details  may  be  performed  without  delay   and 


DIRECT  TRANSFUSION   OF   BL(JOD  1009 

without  speakiri":.  Two  .small  movable  tables,  the  heifrht  of  the  operat- 
ing tables,  are  most  convenient  for  supporting  the  arms  and  the  instru- 
ments during  the  dissection.  One  of  these  tables  will  support  both  arms 
during  the  process  of  making  the  anastomosis  and  during  the  remainder 
of  the  transfusion.  On  either  side  of  this  table  and  between  the  two 
operating  tables  a  stool  is  placed,  which  i)rovides  a  comfortable  and  a 
steady  position  for  the  operator  and  his  first  assistant  vis-d-vis.  From 
the  beginning  until  the  end  not  an  unnecessary  word  is  spoken.  Both 
the  donor  and  the  recipient,  unless  contra-indicated,  are  given  a  pre- 
liminary hypodermic  of  ^  grain  of  morphin  twenty  to  thirty  minutes 
prior  to  their  entrance  to  the  operating  room.  The  patients  are  assui'cd 
that  they  will  experience  no  pain,  save  the  first  needle  prick.  In  order 
that  they  may  not  obtain  a  glimpse  of  the  operating  room  or  of  their 
environment,  both  patients  are  told  that,  owing  to  the  bright  light,  wet 
towels  will  cover  their  eyes,  thus  preventing  a  possible  headache.  They 
are  warned  of  the  first  needle  prick,  and  are  told  that  eocain  will  now 
be  administered,  that  it  will  require  twenty  or  thirty  minutes  to  take 
effect,  and  that  in  the  meantime  it  will  be  necessary  to  massage,  to  prick, 
and  to  pull  the  tissues,  but  that  the  procedure  is  painless.  One  nurse 
is  detailed  to  relieve  the  monotony  of  waiting  by  substituting  fresh 
towels,  bathing  the  brow,  administering  water  if  desired,  and  giving 
helpful  attention. 

Local  ana\sthesia  is  maintained  by  infiltration  of  one  tenth  per  cent 
solution  of  eocain  with  a  few  drops  of  adrenalin,  first  in  the  skin  proper, 
and  then  in  the  neighborhood  of  the  vessels,  after  which  firm  pressure 
for  thorough  dissemination  is  applied.  When  carefully  performed  there 
is  absolutely  no  pain  in  any  part  of  the  procedure  until  the  suture  of 
the  skin  at  the  close  of  the  transfusion,  at  which  time  the  ett'ect  of  the 
eocain  has  disappeared.  In  the  dissection  I  have  found  it  an  advan- 
tage to  use  minute  instruments,  selecting  from  among  the  armamenta- 
rium of  oculists  and  watchmakers.  ]\Iosquito  forceps  are  used  to  catch 
every  vessel  that  sheds  even  a  drop  of  blood,  keeping  the  field  not  only 
clean  but  translucent.  The  donor's  radial  artery  is  isolated  a  distance 
of  about  3  cm.  At  the  point  of  election  there  are  a  number  of  small 
branches  which  should  be  carefully  isolated  and  tied,  otherwise  an  ob- 
scuring haemorrhage  may  occur.  The  small  nerve  branches  and  the 
venae  comites  are  pushed  aside.  The  artery  is  then  tied  at  its  distal 
end,  and  at  the  proximal  a  screw  clamp  gently  closes  its  lumen.  The 
artery  is  then  divided  with  a  sharp  scissors,  the  adventitia  is  drawn 
well  over  its  end  and  snipped  off  closely.  This  leaves  a  clean  open  end 
of  the  vessel,  but  the  manipulation  and  exposure  to  the  air  causes  such 
sharp  contractions  that  for  a  time  its  lumen  is  obliterated.  This  is 
easily  overcome  by  inserting  into  the  lumen  a  mosquito  forceps,  covered 


1010  APPENDIX   I 

with  vaseline,  then  gently  opening  the  blades.  Tliis  overstretching  of 
the  artery's  lumen  prevents  recontraction.  Any  superficial  vein  that 
seems  neither  too  large  nor  too  small  is  likewise  exposed,  isolated,  ligated 
at  its  distal  end,  closed  by  a  screw  clamp  at  its  proximal  part,  divided 
near  the  ligature  with  a  sharp  scissors,  and  its  adventitia  drawn  well 
out  over  the  end  and  snipped  off  closely,  thus  leaving  a  free  manipulable 
end.  The  tables  of  the  donor  and  of  the  recipient  are  approximated 
with  their  heads  in  opposite  directions,  so  that  the  vessels  may  be  ap- 
proximated more  readily  and  the  stream  may  be  transferred  in  nearly 
a  straight  line. 

The  vessels  are  now  compared  with  the  various  sizes  of  the  trans- 
fusion cannula?  and  a  suitable  one  selected.  Then  with  mosquito  for- 
ceps the  handle  of  the  cannula  is  grasped  and  the  cannula  dipped  in 
sterilized  vaseline  or  oil.  The  vein  is  next  pushed  through  the  lumen. 
With  oculist's  small,  self -locking  forceps  or  mosquito  hemostats  the  mar- 
gin of  the  vein  is  grasped,  turning  it  back  as  a  cuff  over  the  outside  of 
the  cannula,  and  a  fine  ligature  of  linen  tied  firmly  around  the  cuff 
in  the  second  groove,  the  ends  of  the  ligature  being  cut  off.  With  one 
hand  the  cannula  is  steadied  by  means  of  the  hemostat,  and  with  small, 
locking  thumb  forceps  or  mosquito  hemostats  the  assistant  and  operator 
grasp  the  end  of  the  artery  at  three  equidistant  points  and  draw  it  over 
the  venous  cuff  and  cannula,  tying  it  snugly  with  a  small  linen  liga- 
ture in  the  first  groove,  thus  completing  the  anastomosis.  The  screw 
clamp  is  then  removed  first  from  the  vein,  then  from  the  artery,  and 
the  fiow  tested.  At  first,  owing  to  the  great  contraction  of  the  artery, 
but  little  blood  flows  across,  but  by  lilieral  application  of  warm  salt 
solution  the  vessel  soon  dilates  and  the  stream  grows  larger,  reaching 
its  maxinnuii  in  about  ten  minutes.  It  is  most  important  not  to  bruise 
the  vessels  or  to  brt'ak  the  intima.  In  every  instance  in  the  51  clinical 
cases  the  technic  was  entirely  successful. 

CONCLT^SIONS 

The  pi'iiieipal  danger  of  transfusion,  now  that  the  technic  is  per- 
fected, is  luemolysis.  Tliis  apparently  occurs  only  in  disease.  The 
dangers  of  ha'molysis  may  be  prevented  by  determining  before  the 
opei-ation  is  undertaken  whether  tlie  blood  of  the  donor  is  hamiolytic 
for  that  of  the  recipient. 

Sufficient  facts  have  been  determined  by  laboratory  experiments  and 
clinical  obsei'vations  to  justify  the  following  conclusions:  Transfusion, 
when  ptoperly  safeguarded,  may  be  safely  done.  In  pernicious  anremia, 
toxii'inia,  certai))  di'ug  poisonings,  leuka'mia,  acute  hyperthyroidism,  and 
ura-mia,  it  has  been  of  no  value.    In  tuberculosis,  carcinoma,  and  chronic 


OPSONINS   AND  THE   INOCULATION   OF   DEAD   BACTERIA       1011 

infections  it,  is  <>!'  (loiihtrnl  or  tit  best  little  v;ilne.  In  liiniinn  sarcoma 
tliere  is  soiik^  evidence  of  value,  thoiii^li  not  yet  proved.  In  patholog- 
ical haanorrhage  it  is  of  marked  value,  in  suitable  cases  it  seems  to 
be  almost  a  speciiic  iu  the  prevention  and  treatment  of  shock.  In  acute 
haemorrhage  in  animals  it  is  specific;  in  human  beings  it  has  proved 
most  valuable. 


APPENDIX    II 

OPSONINS,   PHAGOCYTOSIS,   AND   THE   THERAPEUTIC   INOCULATION   OF 

DEAD   BACTERIA 

The  discovery  of  opsonins  by  Wright  and  Douglas  and  the  intro- 
duction of  the  inoculation  of  dead  bacteria  for  therapeutic  purposes 
mark  an  important  epoch  in  the  studies  of  immunity.  It  cannot  be 
said  at  present  what  the  ultimate  results  of  vaccine  therapy  will  be,  but 
the  outlook  is  so  promising  that  a  brief  consideration  of  the  nature  of 
opsonins  and  the  value  of  the  inoculation  of  dead  bacteria  is  presented 
here. 

The  discovery  by  Wright  and  Douglas  that  the  serum  from  normal 
and  immune  blood  contains  substances,  called  by  them  opsonins,^  which 
have  the  power  to  render  bacti^ria  susceptible  to  phagocytosis,  has  re- 
awakened interest  in  ^Metschnikolf's  theory  of  phagocytic  imnmnity.  It 
has  been  shown  conclusively  that  the  phagocytosis  of  most  bacteria  by 
leucocytes  depends  upon  the  action  of  serum  upon  the  bacteria,  which 
in  some  way  changes  them  so  that  they  are  freely  taken  up  by  poly- 
morphonuclear leucocytes.  Bacteria  suspended  in  salt  solution  resist 
phagocytosis  by  Avashed  leucocytes,  while  bacteria  previously  treated  by 
serum  and  then  Avashed,  i.  e.,  fret'd  from  serum,  are  taken  up  readily 
by  washed  leucocytes.  Bacteria  so  treated  are  said  to  be  sensitized  or 
opsonified.  The  character  of  this  change  is  wholly  unknown.  There 
is  no  recognizable  alteration  in  form,  staining  reaction,  or  function  of 
the  bacteria.     j\Iany  bacteria  grow  freely  in  sera  which  contain  opsonin. 

Normal  opsonins  are  largely  destroyed  by  heating  the  serum  to  60°  C. 
for  thirty  minutes,  some  being  more  .resistant  than  others.  Imnume 
opsonins,  those  produced  as  the  result  of  infection  or  experimental  in- 
oculation of  bacteria,  are  more  resistant.  This  difference  is  attributed 
by  most  authors  to  their  greater  concentration.  This  view  is  supported 
in  a  measure  by  the  fact  that  diluted  innnune  serum  fre(|uently  shows 
a  high  opsonic  value;   when  normal  serum  controls  show   none.      The 

>  From  the  Latin  obsono  or  opsono,  "  I  cater  to,"  "  I  prepare  food  for." 


1012  APPENDIX  II 

whole  question  whether  normal  and  innnnne  opsonins  are  identical  or 
not  is  still  unsettled. 

The  opsonic  index  represents  the  relative  amount  of  an  opsonin  in 
the  serum  of  an  individual  as  compared  with  a  normal  standard  in 
that  case.  The  opsonic  index  with  reference  to  a  given  bacterium  is 
obtained  by  dividing  the  average  number  of  bacteria  taken  up  per 
leucocyte  under  the  influence  of  the  patient's  serum  by  the  average 
number  taken  up  per  leucocyte  under  the  influence  of  the  standard 
normal  serum  under  conditions  which  are  comparable.  The  difficulties 
and  the  numerous  sources  of  error  in  the  determination  of  the  opsonic 
index  are  claimed  by  some  to  be  so  great  as  to  render  the  results  unre- 
liable. The  uniformity  of  results  of  investigators  under  similar  con- 
ditions, their  agreement  with  what  one  would  expect  upon  clinical  and 
other  grounds,  would  seem  to  indicate  that  in  competent  hands  the 
method  is  of  distinct  value.  But  that  it  cannot  be  relied  upon  as  an 
index  of  the  antibacterial  power  of  the  individual  under  all  circum- 
stances is  certain,  because  opsonin,  it  must  be  remembered,  constitutes 
only  one  of  the  antibodies  produced  in  the  reactions  of  immunity. 

It  is  too  early  to  speak  definitely  upon  the  diagnostic  value  of  the 
opsonic  index.  The  conclusions  of  different  investigators  vary  within 
wide  limits,  some  attributing  to  it  much,  others  little  or  no  diagnostic 
value.  From  the  evidence  at  hand  it  is  certain  that  it  can  never  be 
used  as  a  routine  measure  for  the  identification  of  infections,  because 
the  index  may  be  high  or  low  in  a  given  instance,  usually  depending 
upon  whether  the  patient  is  on  the  improve  or  not.  But  that  it  may  be 
of  distinct  value  in  certain  conditions,  just  as  the  agglutinization  of  ty- 
phoid bacilli  is  valuable  in  the  diagnosis  of  typhoid  fever,  is  quite  likely. 

The  evidence  that  inoculation  of  suitable  bacteria  in  proper  amounts 
usually  causes  an  increase  in  the  opsonic  power  of  the  serum  with  re- 
spect to  the  organism  inoculated  is  convincing.  This  is  true  in  the  nor- 
mal individual  or  animal  as  well  as  in  chronic  infections  due  to  the 
corresponding  micro-organism.  Denys  found  that  rabbit  leucocytes  in 
normal  serum  ingested  virulent  streptococci,  but  not  those  made  viru- 
lent by  repeated  passage  through  animals.  In  the  serum  of  the  im- 
munized rabbits  and  horses  the  leucocytes  showed  decided  phagocytic 
power  over  virulent  streptococci.  Bordet,  Besredka,  and  v.  Lingelsheim 
all  noted  the  greatly  increased  phagocytosis  of  streptococci  in  the  pres- 
ence of  immune  serum  both  in  vivo  and  in  vitro.  Metschnikoff  believed 
this  increased  phagocytosis  to  be  due  to  a  stimulation  of  the  leucocytes, 
and  designated  the  substances  assumed  to  stimulate  the  phagocytes  as 
"  stimulins. "  In  the  light  of  the  opsonic  theory  much  of  what  was 
thought  to  be  due  to  the  stimulation  of  the  leucocytes  is  in  reality  the 
restdt  of  opsonificntion.     Neufeld  and  Kimpau  have  shown  that  leuco- 


OPSONINS   AND  THE   INOCULATION   OF   DEAD   BACTERIA       1013 

cytes  digested  in  antistreptococcic  serum  and  then  suspended  in  normal 
serum  failed  to  take  up  virulent  streptococci.  But  disestion  of  virulent 
streptococci  in  antistreptococcic  serum,  then  ^vashed  in  normal  salt 
solution  and  mixed  with  leucocytes,  resulted  in  marked  phagocytosis, 
thus  showing  tliat  in  this  instance  immune  serum  may  so  change  viru- 
lent streptococci  that  leucocytes  ingest  them.  Rosenow  has  not  been 
able  to  render  virulent  pneumococci  susceptible  to  phagocytosis  by  nor- 
mal or  immune  serum,  including  some  of  the  so-called  antipneumococcic 
sera.  The  demonstration  that  opsonins  render  various  bacteria  sus- 
ceptible to  phagocytosis  does  not  prove  fully  that  they  are  of  any  im- 
portance in  combating  infections.  It  nuist  be  shown  that  phagocytosis 
is  the  essential  factor  in  the  destruction  of  certain  bacteria  by  the  blood. 
Hektoen  has  shown  that  in  all  probability  the  relative  imiiuuiity  of  a 
dog  to  anthrax  is  due  to  phagocytosis.  Virulent  anthrax  bacilli  grow 
freely  in  dog  serum,  but  are  destroyed  in  defibrinated  blood  as  the  result 
of  phagocytosis.  Denys  showed  that  in  mixtures  of  normal  ra})bit  leu- 
cocytes and  normal  rabbit  serum  there  was  little  or  no  destruction  of 
virulent  streptococci.  "Whereas,  when  immune  serum  was  substituted, 
prompt  phagocytosis  and  destruction  of  streptococci  took  place.  The 
serum  of  normal  persons  and  patients  with  streptococcus  infections  is 
a  good  culture  medium  for  streptococci.  Ruediger  has  shown  that  nor- 
mal defibrinated  blood,  as  well  as  the  blood  from  patients  with  acute 
infections,  have  a  streptococcidal  effect  which  is  roughly  proportionate 
to  the  number  of  leucocytes  present.  He  shows,  too,  that  the  destruc- 
tion of  streptococci  requires  the  presence  of  opsonins.  RosenoAv  has 
made  analogous  observations  with  respect  to  the  pneumococcus. 

In  practically  all  experimental  work  in  this  field  the  phagocytic 
value  of  leucocytes  is  considered  the  same.  Rosenow  and  Potter,  on  the 
other  hand,  have  shown  that  there  may  be  a  distinct  difference.  The 
former  observer  found  a  greater  phagocytic  activity  of  leucocytes  ob- 
tained from  cases  of  lobar  pneumonia,  endocarditis,  and  other  acute 
infections  associated  with  leucocytosis.  The  difference  was  so  great  in 
a  number  of  instances  that  pneumococci  of  a  grade  of  virulence  which 
resisted  normal  leucocytes  were  taken  up  by  the  leucocytes  engaged  in 
the  infection  under  identical  conditions.  Important  as  these  observa- 
tions are,  it  must  be  remembered  that  they  are  made  with  bacteria 
grown  upon  artificial  media,  and  hence  under  conditions  very  differ- 
ent from  those  in  the  tissue  fluids  or  blood.  The  changes  which  the 
infecting  bacteria  may  acquire  to  protect  themselves  against  the  action 
of  animal  antibodies,  according  to  the  theory  of  AVelch,  nuist  be  dis- 
tinctly borne  in  mii"id  in  this  connection.  Tlie  ])r()mpt  and  pronounced 
phagocytosis  of  different  bacteria  in  the  peritoneal  cavity  in  the  pres- 
ence of  specific  immune  serum  would  seem  to  indicate  that  opsonins 


1014  APPENDIX   II 

play  the  same  part  in  vivo  as  in  vitro.  That  phagocytosis  helps  the 
body  to  rid  itself  of  some  bacteria  is  certain,  but  whether  opsonification 
and  phagocytosis  play  the  primary  role  or  a  secondary  role  is  still 
doubtful.  However  this  may  be,  we  have  in  opsonins  a  new  form  of 
antibody  that  must  be  considered,  especially  in  the  explanation  of  im- 
munity to  those  infections  caused  by  bacteria  whose  destruction  is  not 
accomplished  by  free  lysins  (streptococci,  pneumococci,  etc.). 

The  injection  of  bacterial  products  for  curative  purposes  originated 
with  Koch  when  he  introduced  tuberculin  as  a  remedy  for  tuberculosis. 
Petruschky  and  Richardson  tried  to  hasten  the  reactions  in  the  healing 
process  of  typhoid  fever  by  injecting  products  of  the  typhoid  bacillus. 
Wright  and  Douglas  first  noted  the  rise  in  the  opsonic  power  of  the 
serum  by  injection  of  dead  bacteria  in  chronic  staphylococcus  infections. 
They  also  showed  that  the  opsonic  power  for  tubercle  bacilli  in  tuber- 
culosis greatly  increases  in  response  to  the  injection  of  tuberculin. 
Upon  these  and  other  observations  Wright  places  the  method  of  treat- 
ing infections  by  the  injection  of  the  corresponding  dead  bacteria  or 
bacterial  products  upon  a  scientific  basis.  The  opsonic  index  is  used 
as  a  guide  for  the  time  that  the  injection  is  to  be  made  and  the  amount 
to  be  injected. 

Hektoen  summarizes  as  follows  the  considerations  for  the  therapeu- 
tic inoculation  of  dead  bacteria : 

First,  the  power  of  the  injected  bacterial  substances  to  stimulate  the 
formation  of  opsonins  and  other  specific  antibodies. 

Second,  tlie  belief  that  increased  formation  of  such  substances  may 
hasten  healing  of  the  corresponding  infection. 

Third,  the  apparent  inability  of  the  body  under  certain  conditions 
of  natural  infection  to  produce  such  substances  in  sufficient  quantities 
without  special  stimid;ition. 

The  essential  })rerequisites  for  therapeutic  inoculations  are: 

First,  correct  etiologic  diagnosis. 

Second,  sterilized,  pure  cultures  of  the  bacterium  causing  the  infec- 
tion in  each  disease  or  sterile  products  of  such  bacteria;  and, 

Third,  the  injection  of  proper  doses  at  proper  intervals  so  as  not  to 
unnecessarily  lower  the  antibacterial  power  or  cause  other  unfavorable 
disturbances. 

Experimental  inoculation  as  well  as  auto-inocuhilion  have  a  favorable 
effect  upon  the  course  of  some  chronic  infections,  provided,  as  indicated 
above,  they  do  not  overstinndatc^  the  reactive  powers  of  the  organism. 
The  essential  feature  of  the  Wi-ight  method  is  the  use  of  doses  of  dead 
bacteria,  just  siiCfieient  to  i-nise  the  opsonic  index  above  normal  and  keep 
it  there. 

In   the  tuberculin   treatment   of   local i/.ed   tuberculosis,    Wright  and 


OPSONINS  AND  THE   INOCULATION   OF   DEAD  BACTERIA         1015 

his  adherents  do  not  aim  at  a  tuberculin  immunization,  but  content 
themselves  by  keeping  the  opsonic  index  above  normal.  The  dose  of 
tuberculin  remains  very  small  throughout.  The  method  used  by  Tru- 
deau  and  others  consists  in  giving  progressively  increasing  doses  of 
tuberculin,  but  just  small  enough  to  avoid  a  clinical  reaction.  Tuber- 
culous patients  may  be  made  insusceptible  to  ten  thousand  times  the 
amount  of  tuberculin  which  would  cause  an  initial  reaction.  In  this 
method  no  attention  is  paid  to  the  opsonic  index.  The  coincident  im- 
provement of  the  patient's  condition  so  treated  goes  to  show  that  the 
progressively  increasing  doses  of  tuberculin  without  reference  to  opso- 
nin need  not  be  harmful.  The  former  method  has  been  of  apparent 
value  in  the  treatment  of  chronic  localized  tuberculosis,  excepting  the 
pulmonary  form.  Its  value  in  pulmonary  tuberculosis  is  not  so  defi- 
nitely established.  The  latter  method,  which  has  been  used  for  a  much 
longer  period,  chiefly  in  pulmonary  tuberculosis,  is  believed  by  the  best 
authorities  to  have  a  beneficial  effect  in  many  cases.  That  we  have 
in  tuberculin  a  powerful  remedy  for  the  treatment  of  certain  chronic 
cases  can  scarcely  be  questioned.  But  that  we  have  still  much  to  learn 
of  its  therapeutic  indications  is  equally  certain.  The  reports  of  its 
good  effects  are  not  sufficient  to  warrant  the  giving  up  of  the  well- 
established  surgical  methods,  but  surely  the  surgeon  who  does  not  iLse 
it  in  conjunction  with  other  methods,  or  give  it  a  trial  where  other 
methods  fail,  is  open  to  criticism. 

It  is  impossible  to  estimate  at  this  time  how  much  reliance  is  to  be 
placed  upon  the  therapeutic  inoculation  of  dead  bacteria,  because  as 
yet  chiefly  isolated  cases  have  been  reported.  But  since  the  diseases  in 
which  such  good  results  have  been  reported  recover  spontaneously,  more 
extensive  statistics  and  greater  experience  are  needed  before  any  satis- 
factory conclusions  concerning  the  value  of  the  therapeutic  inoculation 
of  dead  bacteria  can  be  made. 


INDEX 


65 


INDEX 


Alxlomen,  concussion  of,  .518. 

gunshot  wounds  of,  608. 
Abdominal  cavity,  haemorrhage  into,  o'A), 
599. 

organs,  subcutaneous  injuries  of,  599. 

tumors,  diagnosis  of,  768,  955. 

wall,  varices  of,  68.3. 
Abscess,  198. 

incision  of,  198. 
Abscess,  cold,  402,  423,  437,  442. 
treatment  of,  427. 

lymphadenitic,  230. 

lymphangitic,  228. 

metastatic,  209. 

periprocteal,  300. 

retropharyngeal,  424. 

subcutaneous,  208. 

in  general  infections,  286. 

syphilitic,  458,  464. 

tuberculous,  412,  424. 
Abscess  membrane,  209,  419. 
Achillotomy,  708. 
Acid  intoxication,  505. 
Acne  punctata,  206. 

pustulosa,  206. 
Acoin,  125. 
Acromegaly,  737. 
Actinomyces,  365. 
Actinomycosis,  clinical  forms  of,  371. 

diagnosis  of,  373. 

modes  of  infection  in,  365. 

occurrence  of,  in  animals,  308. 
in  man,  368. 

pathology  of,  368. 

prognosis  of,  374. 

treatment  of,  374. 
Actual  cautery  in  treatment  of  wound,  19. 
Adamantinoma,  diagnosis  of,  923. 

histology  of,  922. 

treatment  of,  923. 


Adenomas  of  kidney,  910. 

of  liver,  910. 

of  mammary  gland,  908. 

of  mucous  membranes,  905. 

of  salivary  glands,  908. 

of  skin,  903. 

of  thyroid  gland,  909. 
Adenocarcinoma,  907. 
Adenocystoma,  981. 
Adenomata  sebacea,  904. 

sudoripara,  904. 
Adenomyochondrosarconia,  976. 
Adenomyoma,  889. 
Adenomyosarcoma,  976,981. 
Adenomyxofibroma,  908. 
Adenosarcoma,  908,  974,  975. 
Adrenalin  in  local  anrcsthesia,  119. 
After  care  of  patient,  77. 
Agglutination,  162. 
Agglutinins,  specific,  155. 
Air  embolism,  553. 
Air  infection,  74. 
Air  passages,  freeing  of,  110. 
Albuminuria  due  to  toxins,  162. 
Alcohol,  necrosis  due  to,  29,  495. 

sterilization  with,  5(5. 
Alcohol  compresses,  29,  157,  198. 
Alcohol  injections,  in  elephantiasis,  653. 

in  hirmangiomas,  831. 

in  inoperable  tumors,  775. 
Alexin,  155. 
AUoplasty,  50. 
Alveolar  sarcoma,  844. 
Alypin,  125. 
Amboceptor,  156. 

Ambulatory  treatment  of  fractures,  586. 
Amniotic  adhesions,  642. 
Amputation  neuroma,  895. 
Amrmia  caused  by  toxins,  163. 
Anaesthesia,  general,  accidents  during,  10' 
1019 


1020 


INDEX 


Anaesthesia,  general,  by  sequence,  113. 
cardiac  paralysis  during,  108. 
discovery  of,  86. 
interrupted,  96. 
mortality  following,  117. 
pupillary    and    corneal    reflexes     in, 

97. 
venous  thrombosis  following,  104. 
local,  accidents  during,  118,  125,  126. 
by  freezing,  119. 
by  infiltration,  119. 
by  nerve  blocking,  120. 
by  spraying,  120. 
Ansesthesin,  125. 
Ansesthetic  mixtures,  114. 

palsies,  104. 
Ansesthetics,    late    poisonous    effects    of, 

115,116. 
Anasarca,  645. 
Anatomical  tubercle,  403. 
Anchylosis,  439,  702. 
fibrosa,  266-270. 
ossea,  266-270. 
Aneurysm,  arterial,  by  erosion,  664. 
clinical  course  of,  667. 
congenital,  664. 
dissecting,  665. 
embolic,  864. 
fusiform,  664. 
saccular,  664. 
spontaneous,  664. 
symptoms  of,  666. 
traumatic,  665. 
treatment  of,  673,  675,  677. 
varieties  of,  663,  664. 
arteriovenous,  clinical  course  of,  672. 
symptoms  of,  670. 
varieties  of,  670. 
vessels  involved  in,  671. 
Aneurysmal  sac,  character  of,  665. 
enlargement  of,  666. 
size  of,  666. 
Angina  syphilitica,  464. 
Angio-lipoina,  798. 
Angioma,  822. 

arteriale  racemosum,  829. 
fissurales,  823. 

simplex  hyiierplasticvun,  822. 
Angiosarcoma,  966. 
Angiosdcnjsis,  necrosis  due  to,  499. 
Angiotripsy,  11. 
Annulus  hajmorrhoidalis,  682. 


Anthrax,  bacillus  of,  355. 

carbuncle,  358. 

effects  of  symbiosis  in,  355. 

etiology  of,  355. 

external  forms  of,  357. 

immunization  against,  356. 

in  animals,  355. 

internal  forms  of,  357. 

modes  of  infection  in,  357. 

occurrence  of,  357. 

oedema,  358. 

prognosis  of,  359. 

staining  of  bacilli  of,  355. 

symptoms  of,  359. 

treatment  of,  360. 
Antibodies,  action  of,  in  fever,  166. 

bactericidal,  161. 
Antipyretics,  167. 
Antisepsis,  history  of,  50. 
Antiseptics,  action  of,  upon  tissues,  20. 

for  sterilization,  54-57. 
Antitoxic  serum,  161. 

for  snake  venom,  329. 
Antitoxin,  production  of,  157. 
Aponeuroses,  fibromas  of,  790. 
Apoplexy,  due  to  syphilis,  479. 
Appendices  epiploicse,  lipomas  of,  801. 
Arterial  thrombosis,  496. 
Arteries.     See  also  Blood  vessels. 

aneurysms  of,  663. 

atheroma  of,  661. 

digital  compression  of,  5. 

diseases  of,  233,  661. 

hsemorrhage  from,  4. 

inflammation  of,  233,  661. 

ligation  of,  10,  11. 
in  continuity,  11. 
necrosis  following,  488. 
results  of,  488. 

syphilis  of,  466. 

transfixion  of,  10. 
Artcrioliths,  689. 
Arteriosclerosis,  661. 

results  of,  603. 

syi^hiUtic,  466,  499. 
Arteritis  gangrenosa,  302. 

purulenta,  233. 

syphilitica  obliterans,  466. 
Artery  forceps,  10. 
Arthritis,  acute,  262-266. 
gummatous,  478. 

chronic,  712. 


INDEX 


1021 


Arthritis,  deformans,  71 7. 
diagnosis  of,  71!). 
nature  of,  717. 
pathology  of,  717. 
symptoms  of,  718. 
treatment  of,  719. 

gonorrheal,  2G8. 

haemophiliac,  728. 

metapneumonic,  271. 

neuropathic,  721. 

tuberculous,  428. 

typhoid,  271. 

uriea,  723. 
Arthrodesis,  70G. 
Arthropathy,  in  syringomyelia,  722. 

tabetic,  721. 
Artificial  respiration,  110,  111. 
Artillery,  injuries  by,  608. 
Ascites,  chylous,  558. 
Asepsis,  history  of,  51. 

in  private  practice,  79. 
Asphyxia,  during  anaesthesia,  107. 

local,  512. 
Atheromas,  989. 
Atherosclerosis,  6G1. 
Atrophy  of  bone,  causes  of,  735. 

concentric,  734. 

eccentric,  734. 
Auricular  aj^pendages,  G43. 
Autotransfusion,  15. 
Axillary  lymph  nodes,  tuberculosis  of,  413. 

BaciUus   aerogenes   capsulatus.     See    Ba- 
cillus emi)hysemat()sus. 

coli  communis,  180,  257. 

emphysematosus,  297. 

halosepticus,  257. 

of  malignant  oedema,  298. 

of  pneumonia  in  osteomyelitis,  257. 

pyocyaneus,  183. 

tj-phosus,  188. 
Bacteria,  absorption  of,  154. 

encapsulation  of  virulent,  40. 

invasion  of,  145. 

physiologic  excretion  of,  155. 

toxins  of,  144. 
Bacteriaemia,  281,  317. 
Bacterial  proteins,  145. 
Bactericidal  agents,  source  of,  157-162. 
Bactericidal  power  of  body,  1 55. 

decrease  of,  156. 
Bactericidal  serum,  161. 


Bactericidal  substances,  decrease  of,  156. 
in  tissue  fluids,  155. 

increase  of,  157. 

source  of,  157. 
Bacterio  agglutinins,  155. 
Bacterio  haemolysins,  155. 
Bacterio  lysine,  155. 
Bacteriology  of  the  blood,  316. 
Bandages,  material  for,  64. 
Barlow's  disease,  746. 
Bee  stings,  326. 
Behring's  law,  160. 

Bier's  passive  hj-persemia,  310,  311,  315. 
Blastomycosis,     animal    experiments    in, 
388. 

diagnosis  of,  391. 

geographical  distribution  of,  377. 

history  of,  387. 

infection  atria  for,  390. 

organism  of,  378. 

organs  involved  in,  378. 

pathology  of,  383-385. 

prognosis  of,  392. 

symptoms  of,  381. 

treatment  of,  392. 
Blei)haroplasty,  130. 
Blood,  coagulation  of,  321,  322. 

regeneration  of,  after  haemorrhage,  14. 

transfusion  of,  16. 
Blood  corpuscles,   reaction  of,    to  stains, 
158. 

white,  emigration  of,  148. 
Blood  cysts,  521,  994. 
Blood    examinations    for    bacteria,    292, 

317. 
Blood  extravasation,  absorption  of,  520. 

cutaneous,  520. 

in  fractures,  580. 

subcutaneous,  520. 

submucous,  522. 

subperiosteal,  571. 
Blood  plates,  origin  of,  687. 
Blood  vessels,  formation  of  new,  38. 

injuries  of,  549-551. 

ligation  of,  488,  555. 

mechanical  methods  of  uniting,  557. 

puncturetl  wounds  of,  557. 

repair  of  wounds  in,  557. 

suture  of,  555. 
Boiler  for  instruments,  61. 
Bone  disease  in  mother-of-pearl  workers, 
750. 


1022 


INDEX 


Bone  maYrow,  hiemorrhages  into,  572. 
Bone  plug,  Mosetig-Moorhof,  254. 
Bones,  abnormal  fragility  of,  735,  736. 

abscess  of,  251. 

absorption  of,  49. 

acromegaly  of,  737. 

acute  inflammation  of,  236. 
osteomyelitis  of,  236. 

atrophy  of,  733. 

caries  of,  420,  421. 

chronic  inflammation  of,  251,  420,  474. 

cysticercus  cellulosse  of,  1003. 

echinococcus  of,  1000. 

formation  of,  581. 

gunshot  injuries  of,  604. 

increased  growth  of,  255. 

inflammation  and  disease  of,  236,  733. 
of  marrow  of,  238. 

injuries  and  fractures  of,  571. 

in  osteomalacia,  747. 

in  rachitis,  738. 

in  syringomyelia,  735. 

neuropathies  of,  735. 

suture  of,  593. 

syphilis  of,  469. 

tabetic,  changes  in,  735. 

transplantation  of,  47,  49. 

tuberculosis  of,  416. 

tumors  of,  812. 

uniting  of,  by  nails,  593. 
Botryomycosis,  483. 
Branchial  cysts,  924. 
Brisement  force,  440. 
Bronchopneumonia,  following  anaesthesia, 

98. 
Bubo,  in  glanders,  362. 

inguinal,  231. 
Buck's  extension,  589. 
Burns,  causes  of  death  from,  627. 

different  degrees  of,  621-623. 

etiology  of,  621. 

patholcjgy  of,  62,  627. 

symptoms  of,  626. 

treatment  of,  627. 

X-ray,  628. 
Bursa;,  injuries  of,  538. 
Bursitis,  acute,  273. 
diagnosis  of,  273. 
etiology  of,  272. 
pathohigy  of,  272. 
treatment  of,  274. 

gonorrlifal,  26.3. 


Cadaver  alkaloids,  infection  l)y,  3.30. 
Cadaver  tuberculosis,  403. 
Callus,  amount  of,  formed,  582. 

consolidation  of,  582. 

delayed  formation  of,  583. 
Callus  luxurians,  582. 

Capsula  sequestralis  in  osteomyelitis,  240. 
Caput  medusae,  683. 

obstipum,  traumatic,  527,  704; 
Carbolic  acid,  gangrene,  29,  30,  495. 
Carbonization,  626. 
Carbuncle,  204. 
Carcinoma,  clinical  appearance  of,  928. 

clinical  course  of,  960. 

curability  of,  960. 

early  diagnosis  of,  955. 

etiology  of,  936,  961. 

histogenesis  of,  928. 

histology  of,  935. 

implantation  of,  935. 

medullary,  928. 

metastases  in,  931-933. 

mode  of  growth  of,  930,  931. 

recurrence  of,  961. 

scirrhus,  928. 
Carcinoma  basocellulare,  938. 
Carcinomas  of  glandular  organs,   factors 
predisposing  to,  958. 

gross  appearance  of,  958. 

histology  of,  957. 
Carcinomas  of  mucous  membranes,   clin- 
ical forms,  948. 

factors  predisposing  to,  949. 
Carcinomas  of  skin,  deep,  945. 

distribution  of,  939. 

factors  predisposing  to,  939. 

histology  of,  937. 

lupuslike,  943. 

papillary,  946. 

superficial,  941. 
Cardiac  massage,  111,  112. 

paralysis,  109. 
Caries  carnosa,  421. 

sicca,  433. 

tuberculous,  419. 
Caro  luxurians,  44. 
Cartilage,  fibrillation  of,  717. 

fractures  of,  594. 

injuries  of,  594. 

repair  of  fractures- of,  582. 
('atarrh,  results  of,  223. 

treatment  of,  224. 


INDEX 


1023 


Catgiit,  preparation  of,  60. 

sterilization  of,  69,  70,  71. 
Caustics,  action  of,  613. 

different  kinds  of,  613. 
Cauterization,  for  tiunors,  773. 

scars  following,  614. 

symptoms  of,  613. 
Cellulitis,  i^rognosis  of,  212. 

symptoms  of,  211. 

treatment  of,  212. 
Chancre,  hard,  appearance  of,  -loo. 
diagnosis  of,  456. 
extragenital,  45.5. 
histology  of,  456. 
involution  of,  456. 
treatment  of,  456. 
Cheiloplasty,  131. 

Chemical  injuries,  treatment  of,  615. 
Chemotaxis,  negative,  148. 

positive,  148. 
Chilblains  (perniones),  620. 
Chloroforai,  accidents  during  narcosis  by, 
108,  109. 

action  of  vapor  of,  87. 

after  effects  of,  97. 

apparatus  for  administering,  93. 

chemical  composition  of,  86. 

contraindications  for,  117. 

death  from,  117. 

decomposition  of,  by  gas  flame,  98. 

dropping  of,  93. 

indications  for,  117. 

late  effects  of,  114. 

physical  properties  of,  86. 

physiological  action  of,  90. 

position  of  patient  during,  90. 

preparation  of  patient  for,  87. 

stage  to  be  maintained,  90. 

stages  of,  90. 

statistics  of  deaths  from,  117. 

symptomatology  of  narcosis  of,  94. 

tests  for,  87. 

treatment  of  accidents  during,  107. 
Chloromas,  871. 
Cholesteatoma,  clinical  course  of,  919. 

diagnosis  of,  921. 
Chondritis  sj'philitica,  476. 

tj'phosa,  257. 
Chondrodystrophy,  foetal,  733. 
Chondroma,  diagnosis  of.  811. 

histology  of,  805. 

indications  for  treatment  of,  812. 


Chondroma,   macroscopic  appearance  of, 
805. 

mode  of  growth  of,  806. 

regressive  changes  in,  806. 

sites  for,  807. 

technic  for  removal  of,  811. 
Chondrosarcomas,  851. 
Chondroosteitis  dissecans,  720. 

luetica,  476. 
Chromatophoromas,  879. 
Chromic  acid,  cauterization  with,  613. 
Chylothorax,  558. 
Chylous  cysts,  995. 
Cicatricial  keloid,  41. 
Cicatrix,  formation  of,  40. 

subsequent  changes  in,  38. 
Cirsoid  aneurysm,  829. 
Cocain  anaesthesia,  contraindications  for, 

126. 
Cocain  hydrochlorate,  119. 

indications  for,  126. 
Cocain  solutions,  adrenalin  in,  123. 

poisoning  by,  125. 

technic  of  injecting,  121. 
Coccidioidal  disease,  390. 
Coccus  of  gonorrhoea,  183. 
Cohnheim's  theory,  755. 
Cold,  anaesthesia  by,  119. 

effects  of,  616. 
Cold  abscess,  425. 
Coley's  toxins,  775. 
Collapse,  definition  of,  632. 

etiology  of,  632. 

symptoms  of,  632. 

treatment  of,  633. 
Collateral  circulation,  after  ligation  of  ar- 
teries, 489. 
Colloid  carcinomas,  953. 
Colon  bacillus,  186. 
Coma  diabeticum,  after  anaesthesia,  504. 

prophylaxis  of,  504. 

treatment  of,  505. 
Comedones,  relation  of,  to  atheromas,  989. 
Complement,   156. 
Compound  fractures,  frequency  of,  595. 

treatment  of,  596. 
Compresses,  carbolic  acid,  29. 

moist,  198,  207. 
Conchiolin,  7.50. 
Concussion,  of  abdomen,  518. 

of  brain,  518. 

of  spinal  cord,  518. 


1024 


INDEX 


Concussion  of  thorax,  518. 
Condyloma  acuminatum,  899. 

latum,  457. 
Continuous  suture,  25. 
Contractures,  arthrogenous,  706. 

congenital,  702. 

dermatogenous,  702. 

desmogenous,  702. 

myogenous,  703. 

neurogenous,  704. 

paralytic,  705. 

reflex,  704. 

spastic,  705. 
Contusions,  nature  of,  517. 

symptoms  of,  517. 
Contusions  of  bones,  571. 

of  joints,  559. 
Cornu  cutaneum,  900. 
Corpora  libera  in  joints,  56.3. 

oryzoidea,  431. 
Cotton,  absorbent,  63. 
Coxa  vara,  742. 
Craniotabes,  741. 
Cretinism,  bone  changes  in,  733. 
Cryoscopy,  324. 
Cyanosis,  local,  512. 
Cylindroma,  968. 
Cystadenoma,  903. 

papilliferum,  909. 
Cysticercus,  1002. 

racemosus,  1003. 
Cystocarcinoma  papilliferum,  958. 
Cystosarcoma  phyllodes,  974. 
Cysts,  definition  of,  987. 

exudation,  987. 

liquefaction,  987. 

mucous,  991. 

multilocular,  987. 

of  breast,  993. 

of  pancreas,  994. 

of  salivary  glands,  992. 

of  testicle,  994. 

retention,  987. 

Dactylitis,  syj^hilitic,  473. 
Debris  paradentfiires,  922. 
DecoUement  de  la  peau,  522. 
Decubitas,  491. 

acute,  511. 
Defects,  covering  of,  131. 
Deformities  (contractures)  of  joints,  702. 
Degeneration,  inflammatory,  149. 


Delirium  tremens,  cardiac  weakness  dur- 
ing, 639. 

essential  cause  of,  639. 

prodromata  of,  638. 

symptoms  of,  638. 

treatment  of,  639. 
Demarcation  zone  in  gangrene,  498. 
Dermatol,  27. 
Dermoid  cysts,  contents  of,  912. 

lining  of,  912. 

of  head,  913. 

of  neck,  913. 
Desmoids,  778,  790. 
Diabetes,  traumatic,  642. 
Diabetic  gangrene,  clinical  course  of,  502. 

complications  of,  503. 

dangers  of  anaesthesia  in,  504. 

etiology  of,  501. 

treatment  of,  503. 
Dilatation  cysts,  988. 
Diphtheria,  antitoxin  in,  347. 

baciUi  of,  346. 

causes  of  death  in,  350. 

complications  of,  351. 

diagnosis  of,  351. 

modes  of  infection  in,  347. 

of  skin,  353. 

pathology  of,  349. 

prognosis  of,  350. 

susceptibility  to,  347. 

symptoms  of,  348. 

treatment  of,  352. 
Diphtheritis,  349. 
Diphtheroid,  349. 
Diplococcus  pneumoniae,  178. 
Dislocations    of    joints,    classification    of, 
565,  699. 

complicated,  569. 

complications  of,  567. 

congenital,  699. 

diagnosis  of,  566. 

from  destruction,  269. 

from  distention,  267. 

habitual,  565. 

mechanism  of,  565. 

reduction  of,  567-569. 

symptoms  of,  566. 

traimiatic,  701. 
Distortion  of  joints,  561. 
liiverticulum,  Meckel's,  927. 
Drainage,  capillary,  31. 

tubular,  32,  200. 


INDEX 


1025 


Dressings,  alcohol,  29. 

antiseptic  and  aseptic,  26. 

definitive,  34. 

emergency,  34. 

moist,  29. 

sterilization  of,  00. 
Ductus  linguulis,  cysts  of,  926. 

thoracicus,  injuries  of,  557. 

thyreoglossus,  persistence  of,  926. 

thyreoideus,  cysts  of,  926. 
Dupuytren's  contracture,  703. 
Dura  mater,  endothelioma  of,  963. 
Dysplasia,  chondral,  733. 
Dystrophy,  periosteal,  733. 

Eburnatio  ossis,  in  osteomyelitis,  240. 

syphihtic,  470. 
Ecchondromas,  805. 
Ecchondroses,  805. 
Ecchymoses,  519. 
Echinococcus,  multilocidar,  997. 

of  bone,  1000. 

of  viscera,  998. 

treatment  of,  997. 

unilocular,  997. 
Echinococcus  cysts,  996. 
Eczema,  cause  of,  644. 

different  forms  of,  644. 

following  use  of  antiseptics,  644. 

surgical  significance  of,  644. 

treatment  of,  645. 
Eczema  solare,  621. 
Elephantiasis,  clinical  appearance  of,  650. 

course  of,  649. 

forms  of,  650. 

lobulated,  781. 

pathology  of,  649. 
Elephantiasis  cavernosa,  826. 
Elephantiasis  nervorum,  782. 
Emboli,  bacterial,  280. 

infected,  280,  690. 
Embolism,  clinical  course  of,  490. 

diagnosis  of,  691. 

etiology  of,  496. 

prognosis  of,  496. 

pulmonary,  690. 

symptoms  of,  496. 

treatment  of,  691. 
Embolism,  air,  553. 
Embolism,  fat,  diagnosis  of,  641. 
etiology  of,  640. 
pathology  of,  641. 


Embolism,  fat,  symptoms  of,  ()40. 

treatment  of,  641. 
Embryoma,  cystic,  977. 
Embryonic  rests,  753. 
Emphysema,  gangrenous  or  septic,  301. 

of  chest,  524. 

traumatic,  523. 
Enchondrofibroma,  cystic,  807. 
Enchondroma,  805. 

of  salivary  glands,  971. 
Endangitis  tuberculosa,  445. 
Endarteritis,  chronic  deforming,  661. 

obliterans,  661. 

productiva,  233. 

purulenta,  233. 

syphilitic,  gangrene  due  to,  499. 

tuberculosa,  445. 
Endocardiiun,  myxoma  of,  875. 
Endothelial  cancer,  963. 
Endotheliomas,  963. 
Endothelium,  nature  of,  963. 
Endotoxins,  145. 

action  of,  162. 
Endovasculitis  obliterans  sj^hilitica,  458. 
Enostoses,  818. 
Enterocystoma,  927. 
Ephelides,  832. 

Epidermal  strips  for  grafting,  135. 
Epidermoids,  916. 
Epiphyses,  separation  of,  238,  245. 

traumatic,  574. 
Ei^ithelial  cysts,  912. 

traumatic,  917. 
Epithelial  nests  in  carcinoma,  935. 
Epithehoma,  calcified,  904. 
Epithelioma     adamantinosum     cysticum, 

922. 
Epulides,  791,  854. 
Ergot  gangrene,  513. 
Ergotin  injections  in  frozen  nose,  620. 
Erysipelas,  blood  examinations  in,  217. 

clinical  course  of,  217. 

cocci  of,  213. 

complications  of.  217. 

curative  effect  of,  219. 

diagnosis  of,  217. 

habitual,  216. 

of  mucous  membranes,  215. 

onset,  217. 

l)rognosis  of,  218. 

symptoms  of,  215. 

treatment  of,  218,  219. 


102G 


INDEX 


Erysipelas,  varieties  of,  216. 
Erysipeloid,  clinical  course  of,  220. 

diagnosis  of,  220. 

organism  of,  220. 

treatment  of,  220. 
Erythema,  due  to  chemicals,  613. 

due  to  freezing,  617. 

solare,  621. 
Esmarch's  artificial  ischismia,  6,  7. 

inhaler,  101. 

rubber  bandage,  6,  7. 
tourniquet,  6,  7. 
Ether,  administration  of,  100-102. 

contraindications  for,  117. 

differences  between,  and  chloroform,  99. 

incomplete  anaesthesia  by,  104. 

increase  of  mucus  by,  102. 
of  saliva  by,  102. 

indications  for,  117. 

lung  complications  following,  104. 

physical  properties  of,  99. 

preparation  of,  99. 
Ethyl    chloride,    as    a    local    aniesthetic, 

119. 
Eucain,  125. 
Europhen,  32. 
Excoriations,  518. 
Exenteratio    cranii   by  gunshot   wounds, 

607. 
Exercise  bones,  821. 
Exostoses,  cartilaginous,  813. 

fibrous,  815. 
Exostosis  bursata,  814. 
Explosions,  effects  of,  608. 
Extension  dressings,  modifications  of,  590. 

technic  of  applying,  589. 
Extension,   treatment  of   tuberculous   ar- 
thritis by,  439. 
Extravasation  cysts,  986. 

of  lymph,  522. 
Extravasations   of   blood,   absorption   of, 
520. 

changes  in,  520. 
Extremities,   defective  growth    of,   afl-.T 
fractures,  585. 

deformities  of,  after  fractures,  577. 

dwarfism  of,  733. 

embolism  of,  490. 

freezing  of,  617. 

necrosis  of,  embolic,  496. 
syphilitic,  .')05. 

rickets  of,  742. 


Extremities,  separation  of,  595. 

terminal  defects  of,  733. 
Exudates,  formation  of,  148. 

various  kinds  of,  150,  151. 
Exudation  cysts,  986. 

Facies  tetanica,  339. 
Farcy.     See  Glanders. 
Fascia,  injuries  of,  525-528. 

sarcoma  of,  847. 
Fat,  transplantation  of,  50. 
Fat  emboh,  640. 

after  fractures,  584. 
Fermentation,  294. 
Ferrum  candens,  9. 
Fever,  aseptic,  78,  167. 

causes  of,  165. 

condition  of  respiration  in,  164. 
of  vessels  during,  164,  165. 

definition  of,  163. 

digestion  during,  164. 

disturbance  of  nervous  system  in,  104. 

etiology  of,  165. 

explanation  of,  164. 

fastigium,  164. 

influence  of,  upon  bacteria,  167. 

in  subcutaneous  injuries,  167. 

metabolism  in,  164. 

pathological  changes  in,  166. 

prognosis  of,  165. 

pulse  in,  164. 

surgical  significance  of,  165. 

symptoms  of,  164. 

types  of,  164. 
Fever  curves,  165. 

in  general  infections,  290. 
Fibrin  ferment,  687. 
Fibroepithelial  growths,  898. 
Fibroma  moUuscum,  781. 
Fibromas,  forms  of,  778. 

histology  of,  778. 

mode  of  growth  of,  778. 

of  aponeuroses,  790. 

of  fascia,  790. 

of  glandular  organs,  792. 

of  mucous  membranes,  789. 

of  nerves,  792. 

of  periosteum,  790. 

of  peritoneum,  795. 

of  skin,  780. 

of  subcutaneous  tissues,  789. 
Fibromata  nervorum,  792. 


INDEX 


1021 


Fibrosarcomas,  clinical  course  of,  S44. 

iliagnosis  of,  84 i). 

histology  of,  843. 

intermuscular,  847. 

of  mucous  membranes,  847. 

of  nerves,  849. 

of  periosteum,  848. 

of  skin,  845. 

of  subcutaneous  tissues,  846. 

treatment  of,  8.)0. 
Field  of  operation,  sterilization  of,  73. 
Filaria  sanguinis  hominis,  650. 
Finger,  trigger,  656. 
Fingers,  necrosis  of,  505. 

replacement  of,  by  toes,  139. 
Fistula,  congenital,  925. 

tuberculous,  402. 
treatment  of,  427. 
Fixed  tissue  cells,  proliferation  of,  38. 
Flaps,  cutting  of  pedicle  of,  135. 

form  of,  134. 

inflammation  of,  134. 

method  of  cutting,  133. 

suturing  of,  134. 

venous  stasis  of,  134. 
Flesh  warts,  832. 
Floating  cariilages,  719. 
Fluctuation,  testing  of,  764. 
FcEtal  residues,  753. 

rickets,  733. 
Foetus  in  fcBtu,  984. 
Folliculitis  barbifi,  205. 
Foot,  malum  perforans  of,  513. 
Foreign  bodies,  digestion  of,  45. 

encapsulation  of,  45. 

extrusion  of,  45. 

removal  of,  32,  33. 
Formation  of  new  tissue,  30. 

of  a  cicatrix  in  a  vessel,  557. 

of  fibrillar  connective  tissue,  38. 

of  new  vessels,  38. 
Fractures,  causes  of,  573,  574. 

classification  of,  572,  573. 

complications  of,  575-584. 

delayed  union  of,  583. 

diagnosis  of,  578-580. 

direct  fixation  of,  593. 

displacements,  577. 

immobilization  of,  587. 

massage  of,  592. 

non-union  of,  583. 

pathological,  580. 


Fractures,  prognosis  of,  585. 

reduction  of,  586. 

reduction  of,  by  open  method,  593. 

Roentgen-ray  examination  of,  580. 

symptoms  of,  576. 

traumatic,  580. 

treatment  of,  585. 

varieties  of,  572,  573. 
Fragilitas  tendinum,  529. 
Freckles,  832. 
Freezing,  general,  616. 

local,  617. 
Frost-bites,  first  degree,  617. 

second  degree,  618. 

sequehe  of,  618. 

third  degree,  618. 

treatment  of,  619. 
Functio  la?sa,  in  inflammation,  150. 
Fungus  durffi  matris,  848. 
Fungus  of  joints,  434. 

of  tendon  sheaths  and  bursie,  442. 
Furbringer's  hand  sterihzation,  54. 
Furuncle,  bacteria  found  in,  203. 

complications  of,  203. 

diagnosis  of,  206. 

etiology  of,  203. 

prognosis  of,  206. 

treatment  of,  206. 

varieties  of,  204. 

Galactocele,  993. 
Ganglion,  diagnosis  of,  732. 

etiology  of,  731. 

occurrence  of,  730. 

periosteal,  247. 

symptoms  of,  732. 

treatment  of,  732. 
Ganglio-neuroma,  894. 
Gangrene,  alcohol,  495. 

angiosclerotic,  500. 

carbolic  acid,  29,  30. 

diabetic,  501. 

ergot,  513. 

foudroyant,  301. 

hospital,  308. 

lysol,  495. 

presenile,  500,  501. 

symmetrical,  512. 

syphilitic,  505. 
Gangrene  of  bone,  489. 

of  cheek.     See  Noma. 

of  soft  parts,  487. 


1028 


INDEX 


Gas  phlegmon,  304. 
Gastric  juice,  corrosive  action  of,  495. 
Gauze,  absorbent,  63. 
General  putrefactive  infections,  144. 
General  pyogenic  infections   with  metas- 
tases, 144. 

bacteria  found  in,  282. 

blood  examinations  in,  286. 

chronic  forms  of,  286. 

clinical  course  of,  283,  284. 

diagnosis  of,  286. 

etiology  of,  280,  281. 

fever  in,  284. 

nature  of,  280. 

prognosis  of,  286. 
General  iJyogenic  infections  without  me- 
tastases, 144. 

blood  changes  in,  289. 

definition  of,  144. 

diagnosis  of,  289. 

etiology  of,  287. 

nature  of,  280,  281. 

jjathological  changes  in,  289. 

prognosis  of,  290. 

symptoms  of,  288. 

treatment  of,  291. 
General  reaction,  154. 
Genu  valguiTi  rhachiticum,  742. 

varum  rhacliiticum,  742. 
Gibbus,  tul)erculous,  424. 
Glanders,  in  animals,  362,  363. 

l)acimof,  301. 

clinical  forms  of,  362. 

diagnosis  of,  363. 

infection  atria  in,  362. 

in  man,  363. 

pathology  of,  3(52. 

treatment  of,  364. 
Gliomas,  895. 

diagnosis  of,  897. 

histology  of,  89(i. 

symptoms  of,  89(). 

treatment  of,  897. 

varieties  of,  896. 
Globi,  in  leprosy,  449. 
Gloves,  cotton,  57. 

rubber,  58. 
Glycosuria,  traumatic,  642. 
Gonitis,  tuberculous,  435. 
Gonf)coccic  osteomyelitis,  257. 
Gonococcus,  ISI. 
Gonorrheal  rheumatism,  268. 


Gout,  acute,  724. 

chronic,  725. 

symptoms  of,  723. 

theories  of,  726. 

tophi  in,  725. 

treatment  of,  727. 
Granulation  tissue,  anomalies,  40. 

formation  of,  39,  40,  487. 

granulating  wound  and  ulcer,  44. 

macroscopic  appearance  of,  44. 

secretion  of,  40. 

tuberculous,  400,  401. 

vmhealthy,  44. 
Granulomas,  153. 
Gritti's  amputation,  141. 
Gummata,  cutaneous,  461. 

histology  of,  459. 

macroscopic  appearance  of,  458. 

regressive  changes  in,  459. 

subcutaneous,  469. 
Gummatous  ulcer,  459. 
Gunshot  wounds,  clinical  course  of,  609 

diagnosis  of,  610. 

symptoms  of,  602-004. 

wound  canal  in,  600. 
entrance  of,  601. 
exit  of,  601. 

treatment  of,  611. 
Gunshot  wounds  by  artillery,  608. 
(Jyntr-comastia,  766. 
Gypsum  splints,  587. 

Hiemagglutinins,  155. 
Hiemangio-endothelioma,  965. 
Haemangioma  cavernosum,  825. 

racemosum,  829. 

necrosis  in,  500,  831. 

simplex,  822. 
Jbemarthrosis,  500. 

in  haemophilia,  728. 
1  licmatocele,  981. 
Hematology  in  surgery,  316. 
Hajmatoma,  absorption  of,  520, 

arterial  or  pulsating,  663. 

changes  in,  520. 

clinical  course  of,  520. 

l)ost-operative,  521. 

subperiosteal,  571. 
Hajmatozoa,  examination  for,  319. 
Ha^mocytolysis  in  general  infections,  285. 
I  hemoglobin,  ab.sorption  of,  in  extravasa- 
tions, 520. 


INDEX 


1029 


Htrmoglob'in,  surgical  importance  of,  323. 

Haemolysins,  loo. 

Haemolysis,  163. 

Haemophilia,  control  of  hicmorrhage  in,  13. 

gelatin  injections  in,  13. 

haimatomas  in,  521 . 
Hseniorrhage,  arterial,  4,  552. 

capillary,  4,  552. 

control  of,  555. 

dangers  of,  14. 

death  from,  14. 

prevention  of,  10. 

regeneration  of  blood  after,  14. 

secondary,  553. 

spontaneous  cessation  of,  13. 

symptoms  of,  15. 

treatment  of,  15. 

venous,  4,  552. 
Haemorrhoids,  682. 
Ha^mosiderin,  520. 
Hsemostasis,  by  position,  5. 

by  pressure,  5. 

by  torsion,  11. 

permanent,  10. 

temporary,  5. 
Hemostatic  agents,  5. 
Haemothorax,  60S. 
Halisteresis,  747. 
Hands,  care  of,  59. 

sterilization  of,  53. 
Head  masks,  75. 
Healing,  beneath  a  scab,  41. 

microsco]>ic  phenomena  in,  37,  38. 

of  a  wound,  36. 

per  primam  intentionem,  35. 

per  secvmdam  intentionem,  39. 
Heart,  direct  massage  of,  112. 

gimshot  wounds  of,  608. 

paralysis  of,  during  anaesthesia,  109. 

rupture  of,  599. 
Heat  stroke,  etiology  of,  630. 

treatment  of,  030. 
Hodgkin's  disease,   apj^earance   of  lymph 
nodes  in,  868. 

clinical  characteristics  of,  867. 

clinical  course  of,  868. 

diagnosis  of,  868. 

treatment  of,  870. 
HoUaender's  hot-air  apparatus,  9. 
Holocain,  125. 
Hordeolum,  200. 
Hospital  gangrene,  clinical  course  of,  308. 


Hospital  gangrene,  complications  of,  309. 

diagnosis  of,  309. 

etiology  of,  308. 

forms  of,  308. 

prognosis  of,  309. 

treatment  of,  310. 
Hutchinson's  triad,  460. 
Hydarthros.     See  Hydrops  of  joints. 
Hydatid,  996. 
Hydrocele,  986. 
Hydronephrosis,  988. 
Hydrophobia,  action  of  virus  of,  331. 

attenuation  of  virus  of,  334. 

clinical  course  of,  333. 

diagnosis  of,  333. 

etiology  of,  331. 

experiments  upon,  331. 

in  dogs,  332. 

in  man,  332. 

pathological  anatomy  of,  333. 

prognosis  of,  335. 

protective  inoculation  against,  334. 

treatment  of,  333. 

virus  of,  331. 
Hydrops,  syphilitic,  477. 

tuberculous,  434. 
Hydrops  articularis  chronicus,  560,  712. 
Hydrops  articularis  serosus  and  fibrinosus, 

269,  434,  435. 
Hydrops  follicularis  ovarii,  994. 
Hydrops  processus  vermiformis,  988. 
Hydrops  tuborum,  988. 
Hydrops  vesicae  felleae,  988. 
Hygroma  of  bursae,  659. 
Hygroma  tuberculous,  442. 
Hjqjeriemia,  active  artificial,  157. 

inflammatory,  141. 

passive  (Bier's),  310. 
Hj'pernephroma,  910. 
Hyperostoses,  syphilitic,  474. 
HyiJertrophied  scar,  785. 
Hyphomycetes,  367. 
Hypophysis,  tumors  of,  737. 
Hysteria,  artificial  necrosis  of  skin  in,  514. 

Ice,  in  treatment  of  inflammation,  197. 
Ileus,  dixe  to  volvulus,  493. 
Immvme  bodies,  160. 

specific,  formation  of,  160. 
Immune  sera,  preparation  of,  160,  161. 
Immunization,  160. 
Implantation  carcinoma,  961. 


1030 


INDEX 


Inactivity  atrophy,  654. 

after  fractures,  584. 
Indian  arrow  poison,  330. 
Induration,  Hunterian,  455. 
Infantile  spinal  paralysis,  705. 
Infarct,  hemorrhagic,  690. 
Infections.     See    General  pyogenic    infec- 
tions and  General  putrefactive  in- 
fections. 

surgical,  causes  of,  169. 
Infiltration,  inflammatory,  148. 
Infiltration  anifsthesia,  120. 

haemorrhage  after,  522. 
Inflammation,  causes  of,  169. 

changes  in,  147-149. 

clinical  course  of,  151. 

croupous  and  diphtheritic,  349. 

diagnosis  and  treatment  of,  151,  197. 

nature  of,  147. 

results  of,  152,  153. 

symptomatology  of,  150. 
Infractions  of  bone.     See  Greenstick  frac- 
tures. 
Infusion  of  salt  solution,  16. 

indications  for,  18. 

rectal,  17. 

technic  of,  17. 
Inguinal  lymph  nodes,  syi^hilitic  involve- 
ment of,  457. 

tuberculous,  413. 
Initial  papule,  syjihilitic,  455. 

sclerosis,  syphilitic,  455. 
Injections,  endoneural,  for  anaesthesia,  123. 

perineural,  for  anaesthesia,  123. 
Injuries,  general  remarks  upon,  516. 
Insects,  stings  by,  326. 
Insolation.     See  Heat  stroke. 
Instruments,  arrangement  of,  74. 

reciuired  for  operations,  80. 

sterilization  of,  60. 
Intercostal  neuralgia,  695. 
Intermediary  bodies,  156. 
Intertrigo,  644. 
Intestines,  adenoma  of,  906. 

actinomycosis  of,  372. 

anthrax  of,  357. 

carcinoma  of,  953. 

gangrene  of,  493. 

jHjlyps  of,  907. 

subcutaneous  injuries  of,  599. 

suture  of,  25. 

torsion  of,  410. 


Intestines,  tuberculosis  of,  410. 
Inunction  cure,  480. 
Involucrum,  240. 
Iodoform,  poisoning  by,  31. 
Iodoform  gauze,  30. 

preparation  of,  66. 
lotloform-glycerin  emulsion,  427,  440. 
lodol,  32. 
Iron,  red-hot,  9. 
Ischsemia,  artificial,  7. 

in  gangrene  of  extremities,  497. 

local,  512. 
Ischsemic  contractures,  655. 
Ischsemic  palsy,  655. 
Ivory  pegs,  to  fix  bony  fragments,  49. 

Jaw,  holding  forward  of,  94. 

follicular  cysts  of,  923. 

periosteal  cysts  of,  923. 
Jennerization,  398. 
Joints,  anatomy  of,  262. 

anchylosis  of,  266,  440. 

contractures  of,  702. 

diseases  of,  in  haemophilia,  728. 

dislocations  of,  565. 

gonorrheal,  268. 

inflammation  of,  acute,  263. 
chronic,  712. 
arthritis  deformans,  717. 
gout,  723. 

metastatic,  285. 

neuropathies  of,  721. 

resection  of,  266. 

rheumatic,  713. 

sprains  of,  561. 

synovial  villi  of,  430. 

syphilis  of,  477. 

tuberculosis  of,  428. 

wounds  of,  contused,  559. 
gunshot,  606. 
punctured,  569. 
Julliard  ana>sthetic  mask,  101. 
Junker's  chloroform  ap^Jaratus,  93. 

Keloids,  cicatricial,  784. 

most  common  sites  for,  786. 

multiple,  788. 

recurrence  of,  787. 

spontaneous,  784. 
Keratitis,  neuroparalytic,  510. 

jiarenchymatosa,  460. 
Kyphosis,  in  tuberculous  spondylitis,  424. 


INDEX 


1031 


Lacerated  wouikIs,  characteristics  of,  'A7. 

symptoms  of,  517. 
Larynx,  diphtheria  of,  349. 

oedema  of,  648. 

rhinoscleroma  of,  482. 

stenosis  of,  349. 

syphiHs  of,  404. 

tuberculosis  of,  410. 
Laughing-gas- ansesthesia,  10"),  107. 
Lead  plates  for  suturing,  20. 
Leiomyoma,  consistency  of,  887. 

diagnosis  of,  891. 

distribution  of,  889. 

histology  of,  887. 

regressive  changes  in,  888. 

treatment  of,  891. 
Lentigines,  832. 
Leontiasis  ossea,  736. 
Lepra,  maculoanaesthetica,  452. 

tuberosa,  450. 
Leprosy,  bacilli  of,  448. 

diagnosis  and  prognosis  of,  453. 

history  of  extension  of,  447. 

occurrence  of,  447. 

symptoms  of,  450. 

treatment  of,  453. 
Leucocytes,  emigration  of,  148. 

functions  of,  37. 

phagocytic  properties  of,  38. 

staining  reaction  of,  149. 
Leucocytosis,  inflammatory,  149,  158,320. 

diagnostic  significance  of,  158. 
Leucoplakia,  949. 
Lids,  artificial  formation  of,  130. 
Ligature  en  masse,  11. 
Ligature  of  vessels,  555. 
Light  therapy,  contraindications  for,  773. 

indications  for,  773. 
Lightning,  628. 

stroke,  628. 
Line  of  demarcation,  487. 
Lipocavernoma,  827. 
Lipofibroma,  798. 
Lipoma  arborescens,  430. 
Lipomas,  chagnosis  of,  802. 

etiology  of,  798. 

histology  of,  790. 

macroscopic  appearance  of,  796. 

mode  of  growth  of,  797. 

of  abdominal  cavity,  801. 

of  aponeuroses,  800. 

of  fascia,  800. 


Lipomas,  of  \iscera,  802. 

regressive  changes  in,  798. 

sites  for,  799. 

subfascial,  801. 

symmetrical,  804. 

technic  of  removal  of,  803. 
Liquor  ferri  sesquichlorati,  9. 
Lister's  method  of  treating  wounds,  51. 
Liver,  adenomas  of,  910. 

cavernous  angiomas  of,  827. 

cysts  of,  994. 

subcutaneous  injuries  of,  599. 

sy])hilis  of,  479. 
Local  reaction,  146, 

shock,  517. 
Lucas-Championniere   treatment  of   frac- 
tures, 591. 
Lues.     See  Syphilis. 

Lumbar  anaesthesia.      See    Sinnal    anaes- 
thesia. 
Lungs,  abscess  of,  285. 

actinomycosis  of,  372. 

anthrax  of,  357. 

embolism  of,  585,  641. 

gunshot  wounds  of,  608. 

laceration  of,  599. 

sarcoma  of,  856. 
Lupus,  clinical  course  of,  403. 

forms  of,  406. 

treatment  of,  407. 
Lymph  fistula,  558. 
Lymph  nodes,  acute  inflammation  of,  2.30. 

carcinoma  of,  931. 

extirpation  of  tuberculous.  414. 

scrofulous  enlargement  of,  415. 
Lyinj)h  scrotum,  651. 
Lymi)hadenitis,  purulenta,  230. 

simplex,  229. 

s}^I)hilitic,  457. 

tuberculous,  411,  412,  413. 
Lympha-mia,  868. 
Lymphangiectases,  691. 

causes  of,  692. 

clinical  course  of,  692. 

diagnosis  of,  692. 

treatment  of,  692. 
Ljanphangio-endothelioma,  963. 

distribution  of,  964. 

of  peritoneum,  964. 

of  pleura,  904. 

stroma  of,  904. 
Lymphangioma,  cavernosum,  832. 


1032 


INDEX 


Lymphangioma,  cysticum,  834. 

indications  for  treatment  of,  836. 

origin  of,  835. 

simplex,  831. 

technic  of  removal  of,  836. 
Lymphangitis,  acute,  226. 
treatment  of,  229. 

chronic,  228. 

complications  of,  228. 

diagnosis  of,  228. 

tuberculous,  411. 
Lymphatic  cysts,  994. 
Lymphatic  system,  pyogenic  infections  of, 
226. 

syphilis  of,  466. 

tuberculosis  of,  411. 
LymjDhatic  tissue,  bactericidal  action  of, 

226. 
Lymphatics,  injuries  of,  557. 
Lymphcedema,  692. 
Lymphoma,  malignant,  864. 
Lymphorrhagia,  558. 
Lymphorrhoea,  558. 
Lymphosarcoma,  dia^gnosis  of,  865. 

histology  of,  864. 

indications  for  treatment  of,  866. 

symptoms  of,  864. 
Lysol,  57. 

necrosis  due  to,  495. 
Lyssa.     See  Hydrophobia. 

Machine  injuries,  necrosis  due  to,  488. 

Macromelia,  833. 

Macrosomia,  733. 

Madura  foot,  375. 

Malformations  in  rickets,  742. 

Malignant     lymphoma.     See     Hodgkin's 

disease. 
Malignant  oedema,  304. 
Mallein,  364. 

Malum  perforans  pedis,  513. 
Malum  Pottii,  424. 
Malum  senile,  718. 
Mammary  gland,  adenoma  of,  908. 

carcinoma  of,  959. 

cysts  of,  993. 

fil>roma  of,  792. 
Marrow  of  bone,  actinomycosis  of,  363. 

chronic  inflammations  of,  251. 

echinococcus  of,  1000. 

8jq)hilis  of,  470. 

tuberculosis  of,  421. 


Martin's  bandage,  7. 

Mass  ligature.     See  Ligature  en  masse. 

Mastitis  chronica  cystica,  909. 

Matas  operation,  674. 

Mediastinum,  emphysema  of,  524. 

Melanin,  878. 

Melanoma,  876. 

Macrocheilia,  833. 

Macroglossia,  833. 

Meckel's  diverticulum,  927. 

Melanosarcoma,  characteristics  of,  876. 

clinical  course  of,  881. 

diagnosis  of,  881. 

distribution  of,  877. 

etiology  of,  879. 

involvement  of  lymph  nodes  in,  877. 

metastases  in,  881. 

mode  of  growth  of,  881. 
Melanosis,  881. 
Melanuria,  881. 
Membrane,  pyogenic,  210. 
Meningitis,  279. 

syphilitic,  464. 
Mercurial  poisoning,  60. 
Mercurial  solution,  for  hand  sterilization, 

57. 
Mesenteric  lymph  nodes,  tuberculosis  of, 

413. 
Mesenteric  vessels,  embdlism  of,  497. 
Mesentery,  lipoma  of,  802. 
Metal  clamps,  26. 

fasteners,  26. 

wire,  sterilization  of,  68. 
Metaphysis,  238. 
Metapneiunonic  arthritis,  268. 

osteomyelitis,  257. 
Metastases,  bacterial,  155. 

in  tumors,  931,  933. 
Micrococcus  gonorrhoeai,  181. 

pyogenes  tenuis,  178. 

tetragenus,  180. 
Mikulicz-Wladimirow's  amputation,  141. 
Miliary  tuberculosis,  acute  general,  445. 
Milk  cysts,  993. 
Mixed  infection,  144. 

narcosis,  113. 
Mixed  tumors,  simple,  nature  of,  970. 
of  breast,  974. 
of  salivary  glands,  971. 
of  urogenital  System,  975. 
of  vagina,  976. 
Volkmann's  theory  of,  974. 


INDEX 


1033 


Mixed  tumors,  simple,  Wilm's  theory  of, 
074. 

teratoid,  of  testicle,  980. 

of  various  other  organs,  981. 
Holler's  disease.     See  Barlow's  disease. 
Monoinfections,  144. 
Morphoea.     See  Leprosy. 
Morphin,  for  inoperable  tumors,  776. 

in  general  ana'sthesia,  113. 
Morphin-ether  narcosis,  102. 
Mose tig-Moo rhof  bone  plug,  2'A. 
Mosquito  bites,  326. 
Mouth  gag,  Heister's,  92. 

Koenig-Roser,  92. 
Mucous    membranes,    inflammations    of, 
221,  224,  225. 

injuries  of,  523. 

pyogenic  infections  of,  221. 

syiihilis  of,  463. 

transplantation  of,  141. 

tuberculosis  of,  409. 
Muscle,  atrophic  contractiu'e  of,  655. 

callus  of,  527. 

hematoma  of,  52(5. 

hernia  of,  525. 
Muscles,  atrophy  of,  268,  542,  654. 

congenital  defects  of,  654. 

contusions  of,  525. 

hernia  of,  525. 

injuries  of,  525. 

laceration  of,  526. 

open  injuries  of,  528. 
Muscular  atrophy,  degenerative,  654. 

inactivity,  654. 

reflex,  654. 

simple,  654. 
Myeloid  sarcoma,  853. 
Myelomas,  multiple,  871. 
Myoma.     See     Leiomyoma     and     Rhab- 
domyoma. 
Myositis,  acute  suppurative,  275. 

secondary,  276. 
Myositis  ossificans,  SIS. 

circumscripta,  820. 
progressiva,  819. 
traumatica,  821. 
Myotenotomy,  708. 
Myxomas,  872. 
Myxosarcomas,  clinical  course  of,  873. 

diagnosis  of,  875. 

distribution  of,  873. 

histology  of,  S72. 
66 


Nicvi,    development    of    fibromas     from, 
782. 

development  of  sarcomas  from,  880. 

diagnosis  of,  885. 

histology  of,  883,  884. 

pigmented,  884. 

treatment  of,  885. 
Na;vus,  flammeus,  823. 

pigmentosus,  885, 

pilosus,  883. 

prominens,  883. 

spilus,  883. 

vasculosus,  823. 

verrucosus  (papillomatosus),  824. 
Na3vus  cell  clusters,  885. 
Nffivus  cells,  879,  880. 
Nails,  cleaning  of,  55. 
Narcosis.     See  Antesthesia. 
Nasal  polyps,  790,  906. 
Naso-pharyngeal  polyji,  fibrous,  792. 
Nearthrosis,  formation  of,  583. 
Neck,  fibroma  of,  790. 
Necrobiosis,  487. 
Necrosis,  by  invagination,  491. 

ergot,  513. 

fibrinoid,  of  joints,  431. 

forms  of,  487. 

in  leprosy,  450. 

inflammatory,  149. 

neuropathic,  512,  513. 

of  organs,  490. 

presenile,  499. 

pressure,  491. 

senile,  499. 

symmetrical,  512. 

syphilitic,  505. 

symptoms  of  approaching,  486. 

thermal,  494. 
Necrosis  humida,  487. 

sicca,  487. 
Necrotomy,  254. 
Negri  bodies,  331. 
Neoplasms.     See  Tmnors. 
Nephritis  after  anaesthesia,  87,  104. 
Nerves,  defects  of,  546. 

degeneration  of,  after  injuries,  541. 

grafting  of,  546. 

gunshot  wounds  of,  604. 

injuries  of,  538. 

laceration  of,  539. 

luxations  of,  540. 

neurectomy  in  wounds  of,  696. 


1034 


INDEX 


Nerves,  regeneration  of,  541. 

stretching  of,  539,  696. 

suture  of,  545. 

transplantation  of,  547. 

treatment  of  defects  in,  547. 
Neuralgia,  characteristics  of,  693. 

etiology  of,  694. 

pain  points  in,  694. 

symptomatic,  693. 

symptoms  of,  693. 

treatment  of,  695. 

true,  693. 
Neurectomy,  696. 
Neuritis,  definition  of,  697. 

diagnosis  of,  698. 

etiology  of,  698. 

symptoms  of,  698. 

treatment  of,  698. 
Neurofibroma,  792. 
Neuroglioma  ganglionare,  894. 
Neuroma,  amputation,  895. 

diagnosis  of,  894. 

histology  of,  894. 

symptoms  of,  894. 

treatment  of,  895. 
Neuroma  gangliocellulare,  894. 
Neuropathies  of  bone  and  joints,  721. 
Neuroplasty,  546. 
Neurorrhaphy,  after  treatment  of,  547. 

histological  changes  after,  541. 

results  of,  548. 

secondary,  545. 
Neurotomy,  696. 
New  formation,  of  tissue,  38. 

of  vessels,  38. 
Nirvanin,  125. 

Nitrous  oxid  anesthesia,  105. 
Noma,  bacteriology  of,  305. 

clinical  course  of,  306. 

etiology  of,  305. 

prognosis  of,  307. 

treatment  of,  307. 
No.se,  freezing  of,  017,  618. 

plastic  formation  of,  132. 

scleroma  of,  482. 

syphilis  of,  464,  472. 

tuberculosis  of,  405. 
Novocain,  125. 

Oberst  anaesthesia,  123. 
Occlusive  dressing,  aseptic,  19-34. 
in  army,  19. 


Odontoma,  817,  875. 
CEdema,  malignant,  bacillus  of,  298. 
clinical  characteristics  of,  304. 
of  mucous  membranes,  647. 
of  skin,  cachectic,  646. 
causes  of,  645. 
diagnosis  of,  646. 
ex  vacuo,  646. 
hydraemic,  646. 
inflammatory,  646. 
marantic,  646. 
surgical  significance  of,  648. 
symptoms  of,  648. 
treatment  of,  648. 
Oil  cysts,  798. 
Ointment,  mercurial,  201. 

zinc  oxid,  201. 
Omentum,  lipoma  of,  801. 
Operating  room,  artificial  light  in,  72. 
cleaning  of,  72. 
construction  of,  71. 
location  of,  71. 
Operating  tables,  construction  of,  72. 

in  private  practice,  82. 
Operation,  after  treatment  of,  77. 
alleviation  of  pain  in,  77. 
preparation  for,  73. 

in  private  practice,  81,  82. 
sterilization  of  supplies  for,  63. 
Opsonins,  1011. 

Organization  of  a  thrombus,  689. 
Orthoform,  125. 
Osteitis  deformans,  749. 
diffuse  tuberculous,  421. 
syphilitic,  472. 
Osteoarthritis  chronica  deformans. 

Arthritis  deformans. 
Osteochondritis  dissecans,  564. 

luetica,  476. 
Osteochondroma,  806,  813. 
Osteochondrosarcoma,  806. 
Osteoclasis,  592. 
Osteofibroma,  813. 
Osteoid  chondroma,  852. 

sarcoma,  852. 
Osteoma,  812. 
dead,  816. 

durum  or  eburneum,  812. 
meduUosum,  812. 
of  jaws,  817. 
of  soft  tissues,  818. 
spongiosum,  812. 


See 


i 


INDEX 


1035 


Osteomalacia,  734. 

anatomical  changes  in,  747. 
clinical  course  of,  747. 
definition  of,  747. 
diagnosis  of,  747. 
etiology  of,  747. 
treatment  of,  748. 
Osteomyelitis,  acute  primary,  anatomical 
changes  in,  237. 
bacteriology  of,  2'yCy. 
clinical  course  of,  240. 
clinical  forms  of,  245. 
complications  of,  248. 
diagnosis  and  prognosis  of,  249. 
etiology  of,  23G. 

experimental  production  of,  242. 
sequeliE  of,  254. 
treatment  of,  253,  254. 
chronic  suppurative,  251. 
sclerotizing,  252. 
serosa,  247. 
syphilitic,  472. 
tuberculous,  418. 

anatomical  changes  in,  419. 
clinical  course  of,  423. 
diagnosis  of,  425. 
prognosis  of,  426. 
treatment  of,  426,  427. 
Osteoplastic  flaps,  140. 
Osteoporosis,  734. 
syphilitic,  469. 
Osteopsathyrosis,  734. 
idiopathic,  736. 
syiahilitic,  476. 
Osteosarcoma,  diagnosis  of,  858. 
histology  of,  854. 
indications  for  treatment  of,  861. 
macroscopic  appearance  of,  851. 
mode  of  growth  of,  854. 
myeloid,  853. 
periosteal,  852. 
prognosis  of,  861. 
symptoms  of,  855. 
Osteosclerosis,  phosphorus,  259. 

syphilitic,  473. 
Osteotomy,  592. 
Othsematoma,  571. 
Ovary,  cysts  of,  994. 
dermoids  of,  915. 
mixed  tumors  of,  978. 
necrosis  of,  493. 
Ozoena,  syjihilitic,  464,  473. 


Pachydermia,  647,  689. 

acquisita,  648. 
Paget's  disease  of  bone,  748. 
Paget- Vulpian  theory,  268. 
Palsies,  post-ana?sthetic,  98. 
Panaritium,  suction  treatment  of,  314. 

tendinosum,  273. 
Panarthritis  acuta  puriilenta,  265. 
Panarthritis  in  ha'mojjhilia,  728. 
Pancreas,  cysts  of,  994. 
Pancreatic  juice,  corrosive  action  of,  495. 
Panphlegmon  gangrienosa,  301. 
Papillomas,  clinical  appearance  of,  898. 
etiology  of,  902. 
htemorrhage  from,  902. 
of  brain,  902. 

of  mucous  membranes,  899. 
of  skin,  899. 
symptoms  of,  902. 
treatment  of,  902. 
Papule,  syi:>hilitic,  463. 
Paquelin's  thermocautery,  9. 
Paraffin  cancer,  940. 
Paraffin  injection,  50. 
Paraphimosis,  gangrene  due  to,  493. 
Parasite,  foetal,  984. 

Parasitic  theory  of  tumor  formation,  757. 
Parchment  crackling  in  tumors,  855. 
Parotid  gland,  mi.xed  tumors  of,  971. 
Parthenogenesis  in  development  of  mixed 

tumors,  979. 
Passive    hypersemia.     See    Bier's     treat- 
ment. 
Pasteur  treatment  of  hydrophobia,  334. 
Patient,  after  care  of,  77. 

preparation  of,  73. 
Pectus  carinatum,  742. 
Pemphigus  leprosus,  450. 
Penis,  gangrene  of,  493. 
Penis  bone,  818. 
Periadenitis,  231. 

tuberculous,  414. 
Periangitis  tuberculosa,  445. 
Periarteritis,  233. 
Periosteal-bone  flaps,  139,  140. 
dystrophy,  733. 
sarcoma,  852. 
Periosteum,  fibroma  of,  791. 

injuries  of,  571. 
Periostitis,  acute  hsematogenous,  247. 
albuminosa,  247. 
alveolar,  300. 


1036 


INDEX 


Periostitis,  diffuse  syphilitic,  475. 

gummatous,  474. 

leprous,  453. 

purulenta,  240. 

serosa,  247. 

syphilitic,  470-474. 
Periphlebitis,  235. 
Periprocteal  abscess,  300. 
Perithelioma,  965. 
Peritoneum,  fibroma  of,  795. 
Peritonitis,  278. 

putrefactive,  300. 

tuberculous,  444. 
Perivasculitis  syphilitica,  458. 
Perniones,  620. 
Pes  valgus,  after  trauma,  562. 
Petechise,  519. 
Phagedsena   nasocomialis.     See    Hospital 

gangrene. 
Phagocytosis,  38. 
Pharynx,  diphtheria  of,  348. 
Phlebectases.     See  Varicose  veins. 
Phlebitis  purulenta,  234. 
Phleboliths,  682. 
Phlebotomy,  15. 
Phlegmasia  alba  dolens,  690. 
Phlegmons,  intermuscular,  277. 

putrefactive,  301. 

subcutaneous,  210. 

subfascial,  277. 

woody,  277. 
Phosphorus    necrosis,  clinical    history   of, 
239. 

treatment  of,  260. 
Phosphorus  osteosclerosis,  258. 

periostitis,  258. 
Pia  mater,  tumors  of,  920. 
Pigmented  nicvi,  884. 
Pirogoff's  amputation,  141. 
Plaques  opalines,  464. 
Plasma  cells,  149. 
Plaster-of-Paris  splints,  587. 
Plastic     operations,     by     inversion     aiul 
eversion  of  flaps,  130,  131. 

by  lateral  disi)lacement  of  (laps,  131,  132. 

Ijy  torsion  of  flaps,  131. 

i)y  vmdercutting,  127. 

classification  of,  131. 

fundamental  ])rinci|)les  of,  133. 

with  compound  (i;ips,  139. 
Pleural  exudate,  luemorrhagic,  in  sarcoma, 
850. 


Pleuritis,  278. 

tuberculous,  444. 
Plexiform  neuroma,  793. 
Pneumatocele  cranii,  987. 
Pneumococcic  arthritis,  271. 

osteomyelitis,  257. 
Pneumococcus,  178. 
Podagra,  723. 
Poison,  cadaveric,  330. 
Poliomyelitis  anterior,  705. 
Polydactylism,  733. 
Polyinfections,  144. 
Polyneuritis,  698. 

Polyposis  recti  et  intestini  crassi,  907. 
Polyps,  adenomatous,  904. 

hairy,  981. 

villous,  900. 
Post-ansesthetic  i)alsies,  98. 
Prima  intentio  nervorum,  541. 
Primary  lesion,  syphilitic,  455, 
diagnosis  of,  456. 
treatment  of,  456. 
Projectiles  from  firearms,  effects  of,  603. 

jjenetration  of,  601,  602. 
Proteus  vulgaris,  295. 
Psammoma,  967. 
Pseudarthrosis,  583. 
Pseudoleukaemia,  864. 
Pseudo-membrane,  348. 
Pseudo-paralysis,  syi:)hilitic,  476. 
Psoas  abscess,  424. 
Ptomain,  295. 

Puerperal  infection,  jiutrid,  299. 
Pulse  in  fever,  164. 
Pustula  maligna,  354. 
Putrefaction,  bacteria  of,  295. 

nature  of,  294. 

jiroducts  of,  294. 
Putrefactive  infections,  conditions  essen- 
tial for,  299. 

ectogenous,  299. 

endogenous,  299. 

symptoms  of,  301. 

treatment  of,  303. 
Pya-mia,  bacteria  found  in,  282. 

blood  examinations  in,  286. 

chronic  forms  of,  286. 

clinical  course  of,  283,  284. 

diagnosis  of,  286. 

etiology  of,  280,  281. 

fever  in,  284. 

prognosis  of,  286. 


INDEX 


1037 


Pyremia,  symptoms  of,  285. 

treatment  of,  286. 
Pyocyanin,  184. 
Pyofluorescin,  184. 

Pyogenic  bacteria,  infection  atria  for,  192. 
Pyogenic   infections,    general,    nature   of, 
278-280. 
with  metastases,  280. 
without  metastases,  280. 
prophylaxis,  201. 
treatment  of,  196,  197. 
Pyosalpinx,  988. 
Pyoseptajmia,  294. 

Rabies,  331. 

Radium  rays,  burning  by,  494,  628. 

ulcers  caused  by,  628. 
Rag-sorters'  disease.     Sec  Anthrax. 
Ranidjc,  992. 
Raynaud's  disease,  512. 
Reaction  of  degeneration,  543. 
Receptors,  l"]hrlich's,  160. 
Red-hot  iron,  for  hajmostasis,  9. 
Reflex  asphyxia  during  narcosis,  109. 
Reflex  atrophy,  655. 

after  fractures,  584. 
Reflexes,  corneal,  97. 

pupillary,  97. 
Regeneration  of  nerves,  541. 
of  tendons,  530. 
of  tissues,  38. 
Reinfection,  144. 
Respiration,  artificial,  111. 
Resi>iratory  paralysis,  during  ana;sthesia, 

108. 
Retention  cysts,  987. 
Retroperitoneal  lymph  nodes,  tulxjrculosis 

of,  412. 
Rhabdomyomas,  diagnosis  of,  893. 
distribution  of,  893. 
histology  of,  891. 
treatment  of,  893. 
Rhagades,  ."syphilitic,  463. 
Rheumatism,    chronic    articular,    clinical 
course  of,  715. 
diagnosis  of,  716. 
etiology  of,  714. 
nature  of,  713. 
pathology  of,  714. 
prognosis  of,  716. 
symptoms  of,  715. 
treatment  of,  716. 


Rhinophyma,  652. 

Rhinoplasty,  Italian  method,  132. 

Rhinoscleroma,  -^81. 

Ribbert's  theory,  756. 

Ribs,  tuberculosis  of,  425. 

Rice  bodies  in  joints,  431. 

Rice  body  hygroma,  442. 

Rickets,  anatomical  changes  in,  739. 

course  of,  741. 

definition  of,  738. 

diagnosis  of,  744. 

etiology  of,  744. 

symptoms.of,  743. 

treatment  of,  744. 
Rider's  bone,  820. 
Risus  sardonicus,  339. 
Roentgen  ray,  burns  Ijy,  494,  628. 

diiignosis  of  tumors  by,  858. 

therapy,  773. 

ulcers,  628. 
Rosary,  rachitic,  742. 
Roimd-cell  sarcoma,  843, 
Ru2)ture  of  organs,  3. 

Saber  sheath  deformity  of  tibia,  rachitic, 
742. 

syphilitic,  475. 
Saddle  nose,  syi)hilitic,  474. 
Salt  solution,  administration  of,  17. 

mdications  for,  18. 

preparation  of,  16,  17. 

with  oxygen,  18. 
Salves,  dressing  of,  201. 
Salter's  chloroform  canula,  96. 
Saprtemia,  293. 
Sarcoma,  characteristics  of,  839. 

classification  of,  838. 

definition  of,  838. 

etiology  of,  841. 

fever  with,  841. 

metastases  in,  841. 

mode  of  growth  of,  83i). 

regressive  changes  in,  840. 
Satyriasis,  451. 
Scab,  healing  under,  41. 
Sclerodermia,  408. 

Scopolamin-morphin  anaesthesia,  114. 
Scrofula,  415. 
Scurvy,  infantile,  746. 
Sebaceous  cysts,  989. 
Seborrhrea  senilis,  940. 
Secondary  hiemorrhage,  4. 


1038 


INDEX 


Sepsin,  295. 

Septicaemia,  blood  changes  in,  289. 

cryptogenetic,  289. 

definition  of,  144. 

etiology  of,  287. 

nature  of,  280,  281. 

pathological  changes  in,  289. 

prognosis  of,  290. 

symptoms  of,  288. 

treatment  of,  291. 
Sequestrotomy,  254. 
Sequestrum,  separation  of,  239,  240. 

tuberculous,  419. 
Serum,  hemolytic,  162. 

leucotoxic,  162. 
Shock,  erethistic,  635. 

etiology  of,  635. 

pathologic  physiology  of,  636. 

prognosis  of,  637. 

psychical,  635. 

theories  of,  634. 

torpid,  635. 

treatment  of,  637. 
Shot  suture,  26. 
Side-chain  theory,  159. 
Silk,  preparation  of,  67,  68. 
Silkworm  gut,  68. 
Skin,  burns  of,  621. 

congenital  defects  of,  643. 

congenital  thickening  of,  652. 

frostbites  of,  617. 

gunshot  wounds  of,  603. 

plastic  operations  upon,  134. 

subcutaneous  separation  of,  522. 

tension  planes  of,  1,  2. 

transplantation  of,  135. 
Skin-grafting,  47,  132,  133. 

early  ai)pearance  of  grafted  area  in,  47. 

histol()gic;d  changes  in  grafts  in,  47. 

method  of  repair  in,  47. 

technic  of,  135. 
Skin  grafts,  dressing  of,  136,  137. 
Snake  bites,  326. 
Snake  venom,  action  of,  327,  328. 

proteolytic  ferments  in,  327. 
Soda  solution  for  sterilization,  61. 
Sodium  chloride  infusion.     See  Salt  solu- 
tion. 
Sjiinal  anir'sthesia,  124. 
Sj)in(llo-celI  sarcoma,  843. 
Spirochaita  j)allida,  454. 
Splints,  papier  m.icln',  79. 


Spondylitis,  chronic  anchylosing,  716. 

tuberculous,  424. 
Sprains  of  joints,  diagnosis   and   clinical 
course  of,  562. 

pathology  of,  561. 

prognosis  of,  562. 

treatment  of,  563. 
Spray,  carbolic  acid,  51. 
Staphylococcus  pyogenes,  170,  173. 
Staphylotoxin,  172. 
Steam  sterilizing  apparatus,  65. 
Sterilization,  of  catgut,  68. 

of  dressings,  66. 

of  field  of  operation,  73. 

of  hands,  53. 

of  instruments,  60. 

of  mucous  membranes,  59. 

of  silk,  67. 
Stovain,  in  spinal  ansesthesia,  125. 
Streptococcus  pyogenes,  173,  176. 
Subcutaneous  rupture  of  muscle  and  ten- 
dons, 525,  529. 

treatment  of,  527-530. 
Subcutaneous     salt     infusion.     See     Salt 

solution. 
Subcutin,  125. 

Suffocation  during  anaesthesia,  107. 
Suggillations,  519. 
Sunburn,  621. 
Sunstroke,  etiology  of,  629. 

treatment  of,  630. 
Surgeon  and  assistants,  duties  of,  76. 

preparation  of,  74. 
Suture,  continuous,  22,  25. 

interrupted,  22,  24. 

intestinal,  25. 

mattress,  25. 

of  nerves,  545. 

of  tendons,  532. 

of  vessels,  555. 

quilled,  26. 

twisted,  26. 

tying  of,  22,  23. 
Suture  materials,  67. 
Syncope,  nature  of,  633. 

symptoms  of,  633. 
Synovitis,    chronic    serous,    diagnosis   of, 
713. 
etiology  of,  712. 
symptoms  of,  7L3. 
treatment  of,  714. 

tliagnosis  of,  264,  265. 


INDEX 


1039 


Synovitis,  forms  of,  263. 

sequelae  of,  266. 

treatment  of,  265. 
Syphilis,  diagnosis  of,  460. 

eruptive  stage  of,  457. 

galloping,  457. 

of  bone,  469. 

of  bursa3,  479. 

of  joints,  477. 

of  lymphatic  nodes,  466. 

of  lymphatic  vessels,  467. 

of  mucous  membranes,  40;i. 

of  muscle,  465. 

of  tendon  sheaths,  478. 

of  the  skin,  diagnosis  of,  402. 
lesions  of,  460,  461. 
treatment  of,  463. 

of  viscera,  479. 

treatment  of,  479. 
Syjihilitic  dental  deformities,  460. 

pseudo-paralysis,  476. 
Syphiloderm,  macular,  457. 

papular,  457. 

pustular,  457. 

squamous,  457. 
Syringomyelia,  arthrojiathies  in,  721. 

necrosis  in,  513. 

Tabes,  arthropathies  in,  721. 

necrosis  in,  513. 
Tables,  instrument,  62. 
Taenia  echinococcus,  995. 

saginata,  1002. 

solium,  1002. 
Tampon,  of  iodoform  gauze,  12,  27,  200. 

moist,  29,  201. 
Technic,  aseptic,  51. 

of  blood  examinations,  318. 
Telangiectases,  822. 
Temperature  of  body  in  fever,  164. 
Temporary  dressing,  IS. 
Tenalgia  crepitans,  657. 
Tendon  sheaths,  diseases  of,  657. 

ganglia  of,  658. 

injuries  of,  537. 
Tendon  shortening,  711. 

transplantation,  535,  536,  711. 
Tendons,  ganglion  of,  656. 

open  injuries  of,  531. 

rupture  of,  529. 

subcutaneous  injuries  of,  529. 

subluxation  of,  530. 


Tendons,  thickening  of,  656. 
Tendo-vaginitis,  acute,  diagnosis  of,  273. 
etiology  of,  272. 
pathology  of,  272. 
treatment  of,  274. 

serofibrinous,  657. 

serous,  658. 

sicca,  658. 
Tenoplasty,  indications  for,  710. 

(echnic  of,  710. 
Tenorrhaphy,  532,  533. 
Tenotome,  708. 
Tenotomy,  technic  of,  707. 
Teratoid  tumors,  977. 

of  ovaries,  978. 

of  testicles,  978. 
Teratomas,  982. 
Tetanus,  antitoxin  of,  342. 

bacillus  of,  335. 

clinical  course  of,  338. 

hydrophobicus,  340. 

of  head,  340. 

pathologic  anatomy  of,  341. 

poison  of,  336. 

prognosis  of,  339. 

treatment  of,  341. 

varieties  of,  340. 
Tetanolysin,  336. 
Tetanospasmin,  336. 

absorption  of,  342. 
Tetragenus  (micrococcus),  180. 
Thermo-cautery,  9. 
Thiersch  grafts,  135. 
Thiosinamin,  789. 
Thrombi,  mural,  688. 

obturating,  688. 
Thrombophlebitis,  235. 

treatment  of,  236. 
Thrombosis,  clinical  course  of,  49(). 

etiology  of,  496. 

prognosis  of,  498. 

symptoms  of,  498. 

treatment  of,  498. 
Thrombus,  organization  of,  689. 

red,  white,  and  mixed,  685. 

subsequent  changes  in,  689. 
Thrombus  formation,  factors  concerned  in, 

687. 
Thyreoglossal  cysts,  926. 
Tibia,     saber    sheath    deformity    of,     in 
rickets,  742. 
in  syphilis,  475. 


1040 


INDEX 


Tissue   fluids,   bactericidal  substances  in, 

155. 
Tissues,  regeneration  of,  37,  38,  149. 
Tongue,  rhythmic  traction  of,  112. 
Tonsils,  tuberculosis  of,  410. 
Tophi,  gouty,  725. 

Torsion,  control  of  haemorrhage  by,  12. 
Torticollis,  traumatic,  527. 
Tourniquet,  7. 

Toxic  infections,  general,  281. 
Toxins,  145. 
action  of,  162. 
necrosis  due  to,  496. 
Tracheal  defects,  covering  of,  140. 
Tracheotomy,  350. 
Transfusion  of  blood,  direct,  1007. 

indirect,  16. 
Transplantation,   of   cartilage    and   bone, 
47. 
of  mucous  membrane,  47. 
of  muscles  and  nerves,  49. 
Trauma,  516. 
Tridermoma,  980. 
Trifacial  neuralgia,  695. 
Trismus,  339. 
Tropococain,  125. 
Tubercle,  anatomical,  403. 
bacilli,  394. 
bovine,  394. 
cultures  of,  395. 
demonstration  of,  395,  396. 
immunization  against,  397. 
staining  of,  395. 
toxins  of,  396. 
histology  of,  399. 
regressive  changes  in,  401. 
Tuberculin-R,  397. 

Tuberculosis,  local,  general  treatment  of, 
444. 
miliary,  445. 
of  mucous  membranes,  409,  410. 

treatment  of,  410. 
of  muscle,  408. 
of  serous  membranes,  444. 
of  skin,  clinical  course  of,  406. 
clinical  forms  of,  403,  404. 
treatment  of,  407. 
of  sul>cutaneous  tissues,  408. 
of  viscera,  444. 
Tuberculosis    bursitis,   clinical   course   of, 
443. 
diagnosis  of,  443. 


Tuberculosis  bursitis,  forms  of,  442. 

treatment  of,  443. 
Tuberculous  arthritis,   clinical   course  of, 
434. 

diagnosis  of,  437. 

etiology  of,  428. 

nodular  form  of,  430. 

pathology  of,  429. 

prognosis  of,  438. 

reactive  changes  in,  433. 
spontaneous  healing  of,  433. 

symptoms  of,  434. 

villous,  430. 

treatment  of,  439. 
Tuberculous  lymphadenitis,  diagnosis  of, 
413. 

etiology  of,  411. 

nodes  involved  in,  412,  413. 

pathology  of,  413. 

treatment  of,  414. 
Tuberculous  lymphangitis,  411. 
Tuberculous    osteitis,    clinical    course    of, 
423. 

diagnosis  of,  425. 

diffuse,  421. 

etiology  of,  416,  418. 

pathology  of,  419. 

symptoms  of,  425. 

treatment  of,  426. 
Tuberculous  synovitis,  suppurative,  430. 
Tuberculous       tendo-vaginitis,        clinical 
course  of,  443. 

diagnosis  of,  443. 

forms  of,  442. 

treatment  of,  443. 
Tubulization,  in  suture  of  nerves,  547. 

in  suture  of  vessels,  557. 
Tumor  albus,  436. 

villosus,  900. 
Tumors,  definition  of,  751. 

classification  of,  75.3. 

constitutional  effects  of,  762. 

diagnosis  of,  762. 

etiology  of,  753. 

metastatic  growths  of,  7()0. 

recurrence  of,  760. 

regressive  changes  in,  760. 

treatment  of,  772. 

various  kinds  of,  759. 
Turner's  bone,  821.    - 
Typhoid  bacillus,  188. 

osteomyelitis,  257. 


INDEX 


1041 


Ulcer,  perforating,  .513. 
Ulcus  durum,  455. 

gummosum,  459. 

molle,  455. 
Urachus,  cysts  of,  926. 

fistulae  of,  926. 
Uranoplasty,  1,39. 
Urate  stones,   in  urinary  organs  in  gout, 

723. 
Urinary  infiltration,    putrefactive    phleg- 
mon due  to,  300. 
Urine,  excretion  of  fat  in,  after  fractures, 
641. 

necrosis  due  to,  496. 
Urogenital  system,  mixed  tumors  of,  975. 
Urticaria  gangrsenosa,  514. 
Uterus,  gangrene  due  to  torsion  of,  493. 

myomas  of,  887. 

Vaccine  therapy,  1011. 

Vagina,  mixed  tumors  of,  976. 

Varicocele;  683. 

Varicose  ulcers,  appearance  of,  507. 

diagnosis  of,  508. 

etiology  of,  506. 

location  of,  507. 

treatment  of,  509. 
Varicose  veins,  dangers  of,  683. 

diagnosis  of,  684. 

etiology  of,  506,  681,  682. 

pathology  of,  681. 

results  of,  683. 

treatment  of,  684. 
Varix  aneurysmaticus,  668. 
Vas  deferens,  mixed  tumors  of,  975. 
Venesection,  15. 

technic  of,  15. 
Verruca  carnea,  780. 

necrogenica,  403. 
Vessels,  formation  of  cicatrix  in,  549. 

formation  of  new,  38. 

ligation  of,  555. 

ligation  en  masse  of,  11. 


Vessels,  mechanical  methods  of  repairing, 
557. 

suture  of,  555. 
Vitelline  duct,  cysts  of,  927. 
Viscera,  gangrene  of,  490. 

injuries  of,  599. 
Volvulus,  gangrene  due  to,  493. 
Vox  rauca  leprosa,  451. 

Warts,  hard,  783. 

soft,  780. 
Wasps,  stings  by,  326. 
Water  cancer.     See  Noma. 
Whitlow.     See  Felon  or  Paronychia. 
Wolf  bites,  333. 
W'ounds,  absorption  from,  154. 

cauterization  of,  20. 

classification  of,  1. 

closure  of,  76. 

definition  of,  1. 

dressing  of,  76. 

foreign  bodies  in,  33. 

gaping  of,  1. 

hsemorrhage  from,  3,  4. 

inflammation  of,  147,  196. 

of  muscles  and  tendons,  525,  529. 

of  nerves,  538. 

pain  in,  7,  8. 

primary  union  of,  35. 

secondary  union  of,  39. 

suture  of,  22,  26. 

symptomatology  of,  3,  4. 

time  required  for  healing,  38. 

treatment  of,  19,  22. 
Wound  infections,  bacterial,  143. 

toxic,  143. 
Wound  pain,  3,  4. 

stupor,  517. 

Xanthelasma,  886. 
Xanthoma,  886. 

Xeroderma  i)igmentosum,  relation  of,  to 
carcinoma,  940. 


(2) 


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